Healthcare Provider Details

I. General information

NPI: 1346819307
Provider Name (Legal Business Name): BEWELL PSYCHOTHERAPY PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/23/2021
Last Update Date: 10/31/2025
Certification Date: 10/31/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1821 UNIVERSITY AVE W STE 461-9
SAINT PAUL MN
55104-2801
US

IV. Provider business mailing address

3501 XENIUM LN N APT 123
MINNEAPOLIS MN
55441-2222
US

V. Phone/Fax

Practice location:
  • Phone: 612-421-3178
  • Fax: 612-421-3183
Mailing address:
  • Phone: 612-421-3187
  • Fax: 612-421-3183

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number
License Number State

VIII. Authorized Official

Name: DR. ROSS ELLIOT GUBRUD
Title or Position: MD OWNER
Credential: MD
Phone: 612-421-3187