Healthcare Provider Details

I. General information

NPI: 1558751933
Provider Name (Legal Business Name): KEITH B BLOCK LICSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/23/2015
Last Update Date: 08/25/2026
Certification Date: 08/25/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10201 WAYZATA BLVD STE 100
MINNETONKA MN
55305-1500
US

IV. Provider business mailing address

10201 WAYZATA BLVD STE 100
MINNETONKA MN
55305-1500
US

V. Phone/Fax

Practice location:
  • Phone: 952-544-6806
  • Fax: 952-545-0098
Mailing address:
  • Phone: 952-544-6806
  • Fax: 952-545-0098

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number26533
License Number StateMN
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number5251
License Number StateSD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: