Healthcare Provider Details

I. General information

NPI: 1528265576
Provider Name (Legal Business Name): KEN UJIFUSA PSY.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/02/2007
Last Update Date: 07/29/2021
Certification Date: 07/29/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1665 UTICA AVE S STE 100
ST LOUIS PARK MN
55416-3476
US

IV. Provider business mailing address

8170 33RD AVE S MS 21110Q
BLOOMINGTON MN
55425-4516
US

V. Phone/Fax

Practice location:
  • Phone: 952-541-2500
  • Fax: 952-541-2539
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2083P0901X
TaxonomyPublic Health & General Preventive Medicine Physician
License Number166404
License Number StateMN
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number07187
License Number StateMN
# 3
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number7187
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: