Provider Demographics
NPI:1952763351
Name:WATERSHED PSYCHOLOGICAL SERVICES
Entity Type:Organization
Organization Name:WATERSHED PSYCHOLOGICAL SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CO-OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MEGAN
Authorized Official - Middle Name:JEAN BOOM
Authorized Official - Last Name:SHEDLOCK
Authorized Official - Suffix:
Authorized Official - Credentials:LMFT
Authorized Official - Phone:320-266-4535
Mailing Address - Street 1:4255 PHEASANT RIDGE DR NE
Mailing Address - Street 2:SUITE 412
Mailing Address - City:BLAINE
Mailing Address - State:MN
Mailing Address - Zip Code:55449-4537
Mailing Address - Country:US
Mailing Address - Phone:763-317-6222
Mailing Address - Fax:763-307-3835
Practice Address - Street 1:4255 PHEASANT RIDGE DRIVE
Practice Address - Street 2:SUITE 412
Practice Address - City:BLAINE
Practice Address - State:MN
Practice Address - Zip Code:55391
Practice Address - Country:US
Practice Address - Phone:763-317-6222
Practice Address - Fax:763-307-3835
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-03-24
Last Update Date:2016-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)