Basic Information
| Provider Information | |||||||||
| NPI: | 1629214747 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SVOBODA | ||||||||
| FirstName: | HEATHER | ||||||||
| MiddleName: | LYNN | ||||||||
| NamePrefix: | |||||||||
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| Credential: | MA LP | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | SVOBODA | ||||||||
| OtherFirstName: | HEATHER | ||||||||
| OtherMiddleName: | |||||||||
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| OtherCredential: | MA LP | ||||||||
| OtherLastNameType: | 2 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1501 XERXES AVE N | ||||||||
| Address2: | |||||||||
| City: | MINNEAPOLIS | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554112851 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7635213477 | ||||||||
| FaxNumber: | 7635213893 | ||||||||
| Practice Location | |||||||||
| Address1: | 4432 CHICAGO AVE | ||||||||
| Address2: | |||||||||
| City: | MINNEAPOLIS | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554073519 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6128710118 | ||||||||
| FaxNumber: | 6128710118 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/18/2008 | ||||||||
| LastUpdateDate: | 01/15/2010 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103T00000X | LP5110 | MN | Y | Behavioral Health & Social Service Providers | Psychologist |
No ID Information.