Unknown Individual – Psychologist, NPI 1003809740

Unknown Individual is a healthcare provider. based in Saint paul, Minnesota. specializing in CLINICAL PSYCHOLOGIST. They hold a License No. LP2062 (MN). The NPI Number for Unknown Individual is 1003809740

Main info

Organization
Inactive
38 Years Of Experience
Accepts Medicare Assignment
Name
Unknown Individual
NPI
1003809740
Phone
(651) 290-9088
Address
1137 PORTLAND AVE
Deactivation Date
16 June 2025

Doctor Profile

Medical School Name
OTHER
Secondary Phone
-
Graduation Year
1988 (38 years ago)
PAC ID
0042258667
Professional Enrollment ID
I20050422000726
Address ID
MN551046942SA1137XAVEX300
Data current as of
19 May 2026

Profile Insights

NPPES metrics only — not quality of care.

Methodology
Experience14
Completeness75
Years active:0State licenses:1Digital endpointsOther names

1,110 CLINICAL PSYCHOLOGIST in MN

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Provider Addresses for Unknown Individual

  • 1137, Portland Avenue, Saint Paul, Ramsey County, Minnesota, 55104, United States

    SAINT PAUL, MN 551046942

    Phone: (651) 290-9088

    Mailing address matches the actual address.

NPPES updates history

No NPPES updates recorded for this provider.

Prescription Activity

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Open Payments (CMS)

No Open Payments data available for this provider.

This can happen when there are no reportable CMS Open Payments records.

Medicare Enrollment & Revalidation

Source: CMS public data · Not endorsed by CMS ·

Educational use only—not medical, billing, or legal advice.

No Medicare enrollment or revalidation data available for this provider in our database.

Prepare CMS-855 application → · Look up this NPI in PECOS → · Verify on CMS PECOS

Medicare Utilization (FFS)

Source: CMS public data · Not endorsed by CMS · Beneficiary counts under 11 are suppressed in source data ·

Educational use only—not medical, billing, or legal advice.

No Medicare fee-for-service utilization data available for this provider in our database.

Insurance plans in this area (ZIP 55104)

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Reviews

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Frequently asked questions

What federal number belongs to Unknown Individual?
The federal identifier for Unknown Individual is NPI 1003809740.
Should I trust care from Unknown Individual if status is inactive?
An inactive NPI does not by itself prove someone stopped practicing — check other sources.
What does Unknown Individual treat or focus on?
Patients typically see Unknown Individual under the specialty Psychologist. Clinical services aligned with this taxonomy classification.
What location shows for Unknown Individual?
We surface Saint Paul, Minnesota for Unknown Individual based on available NPPES addresses.
How can I contact Unknown Individual?
Phone or fax may appear on the official NPI record when supplied — verify before relying on them.

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