1801094982 NPI number — MARY R. BOEHLKE PSY.D. P.C.

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1801094982 NPI number — MARY R. BOEHLKE PSY.D. P.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MARY R. BOEHLKE PSY.D. P.C.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1801094982
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/10/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
17935 2ND AVE N
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PLYMOUTH
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55447-3486
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
763-476-4924
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1660 HIGHWAY 100 S
Provider Second Line Business Practice Location Address:
STE. 568
Provider Business Practice Location Address City Name:
ST LOUIS PARK
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55416-1529
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
952-545-6800
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
07/10/2007

Additional Information

Authorized Official

Authorized Official Last Name:
BOEHLKE
Authorized Official First Name:
MARY
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
952-545-6800

Provider Taxonomy Codes

  • Taxonomy code: 103T00000X , with the licence number:  MN LP0708 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1G182BO . This is a "BLUE CROSS OF MN" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".




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