Healthcare Provider Details

I. General information

NPI: 1376534214
Provider Name (Legal Business Name): DOUGLAS ALAN DREW MA, LICSW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/31/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10190 BALTIMORE ST NE SUITE 110
BLAINE MN
55449-5056
US

IV. Provider business mailing address

14701 HARPERS ST NE
HAM LAKE MN
55304-6428
US

V. Phone/Fax

Practice location:
  • Phone: 763-755-7612
  • Fax: 763-775-2048
Mailing address:
  • Phone: 763-413-2829
  • Fax: 763-413-5225

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number7998
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: