Provider Demographics
NPI:1740821214
Name:IMHOLTE, PHILIP DAVID (PSYD)
Entity type:Individual
Prefix:DR
First Name:PHILIP
Middle Name:DAVID
Last Name:IMHOLTE
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3259 ZARTHAN AVE S
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55416-2062
Mailing Address - Country:US
Mailing Address - Phone:320-828-0864
Mailing Address - Fax:
Practice Address - Street 1:3259 ZARTHAN AVE S
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55416-2062
Practice Address - Country:US
Practice Address - Phone:320-828-0864
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-10-04
Last Update Date:2022-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT004270103TC1900X
MNLP6876103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling