Healthcare Provider Details

I. General information

NPI: 1023793254
Provider Name (Legal Business Name): SIMON GENSTERBLUM
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/15/2023
Last Update Date: 12/01/2025
Certification Date: 12/01/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 VETERANS DR
MINNEAPOLIS MN
55417-2309
US

IV. Provider business mailing address

1201 HARMON PL STE 103
MINNEAPOLIS MN
55403-2045
US

V. Phone/Fax

Practice location:
  • Phone: 555-555-5555
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number149.029617
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: