Basic Information
| Provider Information | |||||||||
| NPI: | 1669480521 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DOSS | ||||||||
| FirstName: | ROBERT | ||||||||
| MiddleName: | C | ||||||||
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| Credential: | PSYD LP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2720 FAIRVIEW AVE N STE 100 | ||||||||
| Address2: | |||||||||
| City: | ROSEVILLE | ||||||||
| State: | MN | ||||||||
| PostalCode: | 551131306 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6512415290 | ||||||||
| FaxNumber: | 6512415140 | ||||||||
| Practice Location | |||||||||
| Address1: | 2720 FAIRVIEW AVE N STE 100 | ||||||||
| Address2: | |||||||||
| City: | ROSEVILLE | ||||||||
| State: | MN | ||||||||
| PostalCode: | 551131306 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6512415290 | ||||||||
| FaxNumber: | 6512415140 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/04/2006 | ||||||||
| LastUpdateDate: | 01/19/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/19/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103G00000X | LP4254 | MN | Y | Behavioral Health & Social Service Providers | Clinical Neuropsychologist |
ID Information
| ID | Type | State | Issuer | Description | 362152900 | 05 | MN | MEDICAID |