Provider Demographics
NPI:1104901172
Name:BOCKTING, WALTER O (PHD)
Entity type:Individual
Prefix:
First Name:WALTER
Middle Name:O
Last Name:BOCKTING
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3989 CENTRAL AVE NE
Mailing Address - Street 2:SUITE 300
Mailing Address - City:COLUMBIA HEIGHTS
Mailing Address - State:MN
Mailing Address - Zip Code:55421-3900
Mailing Address - Country:US
Mailing Address - Phone:612-625-1500
Mailing Address - Fax:
Practice Address - Street 1:1300 S 2ND ST
Practice Address - Street 2:SUITE 180
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55454-1075
Practice Address - Country:US
Practice Address - Phone:612-625-1500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-26
Last Update Date:2024-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP2505103T00000X, 103TC0700X
NY020658103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN048313300Medicaid
MN1007664OtherPREFERREDONE
MN602T9BOOtherBLUE CROSS BLUE SHIELD
MN61-81256OtherMEDICA - CHOICE
MN102450OtherUCARE
MNHP50070OtherHEALTHPARTNERS
MN680001632Medicare ID - Type UnspecifiedMEDICARE