Basic Information
Provider Information | |||||||||
NPI: | 1306911821 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | VANLITH | ||||||||
FirstName: | CLINTON | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | PSYD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 500 OSBORNE RD NE STE 255 | ||||||||
Address2: |   | ||||||||
City: | FRIDLEY | ||||||||
State: | MN | ||||||||
PostalCode: | 554322768 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7637866011 | ||||||||
FaxNumber: | 7632362505 | ||||||||
Practice Location | |||||||||
Address1: | 500 OSBORNE RD NE STE 255 | ||||||||
Address2: |   | ||||||||
City: | FRIDLEY | ||||||||
State: | MN | ||||||||
PostalCode: | 554322768 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7637866011 | ||||||||
FaxNumber: | 7632362505 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 11/21/2006 | ||||||||
LastUpdateDate: | 07/21/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103T00000X | 315 | ND | N |   | Behavioral Health & Social Service Providers | Psychologist |   | 103T00000X | LP3858 | MN | Y |   | Behavioral Health & Social Service Providers | Psychologist |   |
ID Information
ID | Type | State | Issuer | Description | LP3858 | 01 | MN | MN BOARD OF PSYCHOLOGY STATE LICENSE | OTHER | 10518 | 05 | ND |   | MEDICAID |