1972640464 NPI number — MS. ELOUISE 'ELLIE' A KNUTSON MSW LICSW

Table of content: MS. ELOUISE 'ELLIE' A KNUTSON MSW LICSW (NPI 1972640464)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1972640464 NPI number — MS. ELOUISE 'ELLIE' A KNUTSON MSW LICSW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KNUTSON
Provider First Name:
ELOUISE 'ELLIE'
Provider Middle Name:
A
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
MSW LICSW
Provider Gender Code:
F

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:
1972640464
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/31/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1535 110TH ST SE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
KERKHOVEN
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
56252-9564
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
320-220-2159
Provider Business Mailing Address Fax Number:
320-235-0099

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1535 110TH ST SE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
KERKHOVEN
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
56252-9564
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
320-220-2159
Provider Business Practice Location Address Fax Number:
320-235-0099
Provider Enumeration Date:
01/31/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 1041C0700X , with the licence number:  11513 , 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: 011064700 . This is a "DHS" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 20519475456201A006 . This is a "TRICARE WEST" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: HP85447 . This is a "HEALTH PARTNERS HPPID" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 70L94KN . This is a "BCBSMN" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 800002451 . This is a "MEDICARE PTAN" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".




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