Basic Information
| Provider Information | |||||||||
| NPI: | 1104901172 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BOCKTING | ||||||||
| FirstName: | WALTER | ||||||||
| MiddleName: | O | ||||||||
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| Credential: | PHD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3989 CENTRAL AVE NE | ||||||||
| Address2: | SUITE 300 | ||||||||
| City: | COLUMBIA HEIGHTS | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554213900 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6126251500 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1300 S 2ND ST | ||||||||
| Address2: | SUITE 180 | ||||||||
| City: | MINNEAPOLIS | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554541075 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6126251500 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/26/2006 | ||||||||
| LastUpdateDate: | 07/07/2008 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103T00000X | LP2505 | MN | N | Behavioral Health & Social Service Providers | Psychologist | 103TC0700X | LP2505 | MN | Y | Behavioral Health & Social Service Providers | Psychologist | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 61-81256 | 01 | MN | MEDICA - CHOICE | OTHER | 048313300 | 05 | MN | MEDICAID | 602T9BO | 01 | MN | BLUE CROSS BLUE SHIELD | OTHER | HP50070 | 01 | MN | HEALTHPARTNERS | OTHER | 102450 | 01 | MN | UCARE | OTHER | 1007664 | 01 | MN | PREFERREDONE | OTHER |