Healthcare Provider Details

I. General information

NPI: 1912810516
Provider Name (Legal Business Name): THOMAS RUSSELL BARE
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/24/2026
Last Update Date: 09/24/2026
Certification Date: 09/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5010 CHESHIRE LN N
PLYMOUTH MN
55446-3863
US

IV. Provider business mailing address

6590 CHESSHIRE LN N
MAPLE GROVE MN
55311-3429
US

V. Phone/Fax

Practice location:
  • Phone: 612-439-4650
  • Fax:
Mailing address:
  • Phone: 763-232-3322
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: