Healthcare Provider Details

I. General information

NPI: 1053991448
Provider Name (Legal Business Name): SUMUS HEALTH, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/10/2021
Last Update Date: 04/10/2021
Certification Date: 04/10/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6020 302ND ST
STACY MN
55079-9649
US

IV. Provider business mailing address

6020 302ND ST
STACY MN
55079-9649
US

V. Phone/Fax

Practice location:
  • Phone: 612-418-9391
  • Fax:
Mailing address:
  • Phone: 612-418-9391
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number
License Number State

VIII. Authorized Official

Name: DR. RICHARD ANTHONY BLACKBURN
Title or Position: CO-OWNER
Credential: PHD
Phone: 612-418-9391