Provider Demographics
NPI:1780691592
Name:GARRETT, WILLIE BERNARD (MS-LP, EDD)
Entity type:Individual
Prefix:DR
First Name:WILLIE
Middle Name:BERNARD
Last Name:GARRETT
Suffix:
Gender:M
Credentials:MS-LP, EDD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1600 UNIVERSITY AVE W STE 505
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55104-3825
Mailing Address - Country:US
Mailing Address - Phone:651-645-0980
Mailing Address - Fax:651-645-3534
Practice Address - Street 1:1600 UNIVERSITY AVE W STE 505
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55104-3825
Practice Address - Country:US
Practice Address - Phone:651-645-0980
Practice Address - Fax:651-645-3534
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP1234103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist