Provider Demographics
NPI:1699704932
Name:NIEMI, EDWIN EUGENE (PSYCHOLOGIST)
Entity type:Individual
Prefix:
First Name:EDWIN
Middle Name:EUGENE
Last Name:NIEMI
Suffix:
Gender:M
Credentials:PSYCHOLOGIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1401 EAST FIRST STREET
Mailing Address - Street 2:
Mailing Address - City:DULUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55805
Mailing Address - Country:US
Mailing Address - Phone:218-728-4491
Mailing Address - Fax:218-728-4404
Practice Address - Street 1:629 1ST AVE
Practice Address - Street 2:
Practice Address - City:TWO HARBORS
Practice Address - State:MN
Practice Address - Zip Code:55616-1505
Practice Address - Country:US
Practice Address - Phone:218-834-5520
Practice Address - Fax:218-834-4264
Is Sole Proprietor?:No
Enumeration Date:2006-06-30
Last Update Date:2014-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LP2144103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN078047200Medicaid
MN078047200Medicaid