Individual
DOUGLAS MICHAEL WHITESIDE
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
PHD
Contact information
Practice address
909 FULTON ST SE, MINNEAPOLIS, MN 55455-4800
(612) 672-7422
Mailing address
720 WASHINGTON AVE SE STE 300, MINNEAPOLIS, MN 55414-2904
Taxonomy
Speciality
Code
Description
License number
State
103G00000X
Clinical Neuropsychologist
LP6425
MN
103T00000X
Psychologist
073858
IA
103T00000X
Psychologist
2492
WA
103T00000X
Psychologist
Primary
LP6425
MN
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
071008267
STATE LICENSE
IL
01
—
2492
WA CLINICAL PSYCHOLOGY
WA
01
—
LP6425
STATE LICENSE
MN
Enumeration date
06/08/2006
Last updated
03/24/2021
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