Healthcare Provider Details

I. General information

NPI: 1487949939
Provider Name (Legal Business Name): ANDRE BENNETT HEUER LICSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/13/2011
Last Update Date: 06/13/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17305 CEDAR AVE S SUITE 230
LAKEVILLE MN
55044-3901
US

IV. Provider business mailing address

17305 CEDAR AVE S SUITE 230
LAKEVILLE MN
55044-3901
US

V. Phone/Fax

Practice location:
  • Phone: 952-898-6210
  • Fax:
Mailing address:
  • Phone: 952-898-6210
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number9081
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: