Provider Demographics
NPI:1942380316
Name:OSTROM, JANICE L (MS, LP)
Entity type:Individual
Prefix:
First Name:JANICE
Middle Name:L
Last Name:OSTROM
Suffix:
Gender:F
Credentials:MS, LP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4535 WASHBURN AVE N
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55412-1055
Mailing Address - Country:US
Mailing Address - Phone:612-522-3945
Mailing Address - Fax:612-522-5124
Practice Address - Street 1:4535 WASHBURN AVE N
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55412-1055
Practice Address - Country:US
Practice Address - Phone:612-522-3945
Practice Address - Fax:612-522-5124
Is Sole Proprietor?:No
Enumeration Date:2006-10-17
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP 3197103TB0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & Behavioral
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNLP 3194OtherLICENSED PSYCH. #
MN60D83OSOtherBLUE CR/SHEILD PIN#