Provider Demographics
NPI:1730193954
Name:LOWERY, ELLEN (PHD, LP)
Entity type:Individual
Prefix:DR
First Name:ELLEN
Middle Name:
Last Name:LOWERY
Suffix:
Gender:F
Credentials:PHD, LP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7600 BOONE AVE N
Mailing Address - Street 2:SUITE 2
Mailing Address - City:BROOKLYN PARK
Mailing Address - State:MN
Mailing Address - Zip Code:55428-4563
Mailing Address - Country:US
Mailing Address - Phone:763-515-2450
Mailing Address - Fax:
Practice Address - Street 1:7600 BOONE AVE N
Practice Address - Street 2:SUITE 2
Practice Address - City:BROOKLYN PARK
Practice Address - State:MN
Practice Address - Zip Code:55428-4563
Practice Address - Country:US
Practice Address - Phone:763-515-2450
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-27
Last Update Date:2014-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN00091103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN21266OtherHP
MN512716500Medicaid
MN61-52204OtherUBH
MN26D11LOOtherBCBS
MN1012053OtherP1
MN114927OtherUC
MN148951OtherCP
MN114927OtherUC