Basic Information
| Provider Information | |||||||||
| NPI: | 1164520284 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SHAGALOW | ||||||||
| FirstName: | JOSEPH | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | PSYD LP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7200 FRANCE AVE | ||||||||
| Address2: | STE 327 | ||||||||
| City: | EDINA | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554354310 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9528352002 | ||||||||
| FaxNumber: | 9528359889 | ||||||||
| Practice Location | |||||||||
| Address1: | 7200 FRANCE AVE | ||||||||
| Address2: | STE 327 | ||||||||
| City: | EDINA | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554354310 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9528352002 | ||||||||
| FaxNumber: | 9528359889 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/20/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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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 | LP4413 | MN | Y | Behavioral Health & Social Service Providers | Psychologist |
ID Information
| ID | Type | State | Issuer | Description | 6192891 | 01 | MN | MEDICA | OTHER | 150R5BH | 01 | MN | BCBS | OTHER | 171138 | 01 | MN | UCARE | OTHER | HP39213 | 01 | MN | HEALTH PARTNERS | OTHER |