Healthcare Provider Details

I. General information

NPI: 1811281645
Provider Name (Legal Business Name): COLE ANTHONY BUCHTEL L.I.C.S.W
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/09/2011
Last Update Date: 05/18/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2385 ARIEL ST N
MAPLEWOOD MN
55109
US

IV. Provider business mailing address

4201 EXCELSIOR BLVD
MINNEAPOLIS MN
55416-4728
US

V. Phone/Fax

Practice location:
  • Phone: 651-528-6169
  • Fax: 651-528-6583
Mailing address:
  • Phone: 952-933-8900
  • Fax: 952-945-9536

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number16129
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: