Minneapolis Southwest Mental Health Clinic, Limited

Primary specialty

PsychologistTaxonomy code 103T00000X

License

LP2893 Issued in MN

Legal business name

MINNEAPOLIS SOUTHWEST MENTAL HEALTH CLINIC, LIMITED

Practice address

4010 W 65TH St Ste 101
Edina, MN 55435-1724

Phone

(952) 831-4499

NPI assigned

May 10, 2007

Organization subpart

No

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name

Mr. Dale Bremner Peterson, MALP

Title

President

Phone

(952) 831-4499

Specialties & licenses 1

Addresses

Other identifiers 1

Locations

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1178755200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1598054400000",
    "number": "1649485111",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "4010 W 65TH ST STE 101",
            "city": "EDINA",
            "state": "MN",
            "postal_code": "554351724",
            "telephone_number": "952-831-4499"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "4010 W 65TH ST STE 101",
            "city": "EDINA",
            "state": "MN",
            "postal_code": "554351724",
            "telephone_number": "952-831-4499"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "MINNEAPOLIS SOUTHWEST MENTAL HEALTH CLINIC, LIMITED",
        "organizational_subpart": "NO",
        "enumeration_date": "2007-05-10",
        "last_updated": "2020-08-22",
        "status": "A",
        "authorized_official_last_name": "PETERSON",
        "authorized_official_first_name": "DALE",
        "authorized_official_middle_name": "BREMNER",
        "authorized_official_title_or_position": "PRESIDENT",
        "authorized_official_telephone_number": "952-831-4499",
        "authorized_official_name_prefix": "Mr.",
        "authorized_official_credential": "MALP"
    },
    "taxonomies": [
        {
            "code": "103T00000X",
            "taxonomy_group": "193400000X SINGLE SPECIALTY  GROUP",
            "desc": "Psychologist",
            "state": "MN",
            "license": "LP2893",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "BLUECROSSBLUESHIELD",
            "identifier": "11702MI",
            "state": "MN"
        }
    ],
    "endpoints": [],
    "other_names": []
}

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• Psychologist in Edina, MN
• Providers in Edina, MN by specialty
• Psychologist in Minnesota

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Aug 22, 2020; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.