Healthcare Provider Details

I. General information

NPI: 1669733762
Provider Name (Legal Business Name): BOSAK MISCHKE INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/05/2012
Last Update Date: 06/05/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

821 RAYMOND AVE #300
SAINT PAUL MN
55114-1525
US

IV. Provider business mailing address

821 RAYMOND AVE #300
SAINT PAUL MN
55114-1525
US

V. Phone/Fax

Practice location:
  • Phone: 651-647-0659
  • Fax: 651-646-1424
Mailing address:
  • Phone: 651-647-0659
  • Fax: 651-646-1424

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License NumberLP2396
License Number StateMN
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number4213
License Number StateMN

VIII. Authorized Official

Name: JOHN MISCHKE
Title or Position: PRESIDENT
Credential:
Phone: 651-647-0659