Healthcare Provider Details

I. General information

NPI: 1003213299
Provider Name (Legal Business Name): NATHAN FOOTE LICSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/03/2014
Last Update Date: 10/28/2024
Certification Date: 10/28/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8550 HUDSON BLVD N
LAKE ELMO MN
55042-5500
US

IV. Provider business mailing address

1100 GLENWOOD AVE
MINNEAPOLIS MN
55405-1430
US

V. Phone/Fax

Practice location:
  • Phone: 651-254-8580
  • Fax:
Mailing address:
  • Phone: 612-871-1454
  • Fax: 612-871-1505

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number21133
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: