Provider Demographics
NPI:1306911821
Name:VANLITH, CLINTON (PSYD)
Entity type:Individual
Prefix:
First Name:CLINTON
Middle Name:
Last Name:VANLITH
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:500 OSBORNE RD NE STE 255
Mailing Address - Street 2:
Mailing Address - City:FRIDLEY
Mailing Address - State:MN
Mailing Address - Zip Code:55432-2768
Mailing Address - Country:US
Mailing Address - Phone:763-786-6011
Mailing Address - Fax:763-236-2505
Practice Address - Street 1:500 OSBORNE RD NE STE 255
Practice Address - Street 2:
Practice Address - City:FRIDLEY
Practice Address - State:MN
Practice Address - Zip Code:55432-2768
Practice Address - Country:US
Practice Address - Phone:763-786-6011
Practice Address - Fax:763-236-2505
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-21
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND315103T00000X
MNLP3858103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNLP3858OtherMN BOARD OF PSYCHOLOGY STATE LICENSE
ND10518Medicaid
S43306Medicare UPIN