Healthcare Provider Details

I. General information

NPI: 1386329704
Provider Name (Legal Business Name): ASHLEY NORTHRUP CLINICAL TRAINEE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/21/2023
Last Update Date: 09/01/2026
Certification Date: 09/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7901 XERXES AVE S STE 110
BLOOMINGTON MN
55431-1200
US

IV. Provider business mailing address

16536 HORIZON AVE
LAKEVILLE MN
55044-6817
US

V. Phone/Fax

Practice location:
  • Phone: 763-607-7817
  • Fax:
Mailing address:
  • Phone: 952-334-6168
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number04760
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: