Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 103TC1900X | Counseling Psychologist | LP2995 | MN |
NPI | 1114012697 |
---|---|
Provider Name | Glen Staffan Bjornson |
First Address | Mahtomedi, MN 55115-1833 |
Second Address | Woodbury, MN 55125-2290 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 03/10/2006 |
Last Update Date | 08/07/2007 |