Healthcare Provider Details

I. General information

NPI: 1710647425
Provider Name (Legal Business Name): THOMAS JOHN HEGBLOM PHD, LPC, LADC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/21/2021
Last Update Date: 11/02/2022
Certification Date: 11/02/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3033 EXCELSIOR BLVD STE 215
MINNEAPOLIS MN
55416-5274
US

IV. Provider business mailing address

6501 OLSON MEMORIAL HWY
GOLDEN VALLEY MN
55427-4948
US

V. Phone/Fax

Practice location:
  • Phone: 612-217-2828
  • Fax:
Mailing address:
  • Phone: 763-234-8724
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number3597
License Number StateMN
# 2
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number304627
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: