Basic Information
| Provider Information | |||||||||
| NPI: | 1063146538 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | EDDY | ||||||||
| FirstName: | ROBERT | ||||||||
| MiddleName: | WAYNE | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | MA, LMFT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 10310 41ST AVE N | ||||||||
| Address2: | |||||||||
| City: | PLYMOUTH | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554411536 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7633123660 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1900 SILVER LAKE RD NW STE 110 | ||||||||
| Address2: | |||||||||
| City: | NEW BRIGHTON | ||||||||
| State: | MN | ||||||||
| PostalCode: | 551121789 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6516289566 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/12/2022 | ||||||||
| LastUpdateDate: | 07/12/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 07/12/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106H00000X | 4243 | MN | Y | Behavioral Health & Social Service Providers | Marriage & Family Therapist |
No ID Information.