1649564188 NPI number — BLUE IRIS THERAPY, PLLC

Table of content: (NPI 1649564188)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1649564188 NPI number — BLUE IRIS THERAPY, PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BLUE IRIS THERAPY, PLLC
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:
6
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:
1649564188
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/01/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6437 LYNDALE AVE S
Provider Second Line Business Mailing Address:
SUITE 101
Provider Business Mailing Address City Name:
RICHFIELD
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55423-1465
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
612-455-4040
Provider Business Mailing Address Fax Number:
612-455-4041

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6437 LYNDALE AVE S
Provider Second Line Business Practice Location Address:
SUITE 101
Provider Business Practice Location Address City Name:
RICHFIELD
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55423-1465
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
612-455-4040
Provider Business Practice Location Address Fax Number:
612-455-4041
Provider Enumeration Date:
06/01/2011

Additional Information

Authorized Official

Authorized Official Last Name:
CHIKAZAWA-NELSON
Authorized Official First Name:
GRANT
Authorized Official Middle Name:
D
Authorized Official Title or Position:
OWNER/PSYCHOTHERAPIST
Authorized Official Telephone Number:
612-655-9776

Provider Taxonomy Codes

  • Taxonomy code: 251S00000X , with the licence number:  943 , 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: 227349918 . This is a "MEDICA-UBH" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 540521 . This is a "VALUE OPTIONS" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 143645 . This is a "U-CARE" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 529100300 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 550045 02 . This is a "BHP" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 69B22CH . This is a "BC/BS" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".




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