Basic Information
| Provider Information | |||||||||
| NPI: | 1629150479 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | TRUITT | ||||||||
| FirstName: | NAN | ||||||||
| MiddleName: | C | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PH.D., LP | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | BOLSINGER | ||||||||
| OtherFirstName: | NAN | ||||||||
| OtherMiddleName: | C | ||||||||
| OtherNamePrefix: | |||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 2925 CHICAGO AVE | ||||||||
| Address2: | |||||||||
| City: | MINNEAPOLIS | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554071321 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6122625000 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 265 PHALEN BLVD | ||||||||
| Address2: | |||||||||
| City: | SAINT PAUL | ||||||||
| State: | MN | ||||||||
| PostalCode: | 551302400 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6514956603 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/20/2006 | ||||||||
| LastUpdateDate: | 10/04/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103G00000X | 593 | AK | N | Behavioral Health & Social Service Providers | Clinical Neuropsychologist | 103TA0400X | 593 | AK | N | Behavioral Health & Social Service Providers | Psychologist | Addiction (Substance Use Disorder) | 103TC0700X | 593 | AK | N | Behavioral Health & Social Service Providers | Psychologist | Clinical | 103TF0200X | 593 | AK | N | Behavioral Health & Social Service Providers | Psychologist | Forensic | 103TM1800X | 593 | AK | N | Behavioral Health & Social Service Providers | Psychologist | Mental Retardation & Developmental Disabilities | 103G00000X | 5880 | MN | Y | Behavioral Health & Social Service Providers | Clinical Neuropsychologist |
ID Information
| ID | Type | State | Issuer | Description | 1029222 | 05 | AK | MEDICAID |