=====================================================
General NPI Number Information
=====================================================
NPI Number | 1275210338
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | BLAINE ROBERT BOVERHUIS MSW, LICSW
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/30/2023
-----------------------------------------------------
Last Update Date | 06/30/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6401 FRANCE AVE S
-----------------------------------------------------
City | EDINA
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55435-2104
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 952-924-2888
-----------------------------------------------------
Fax | 952-924-2880
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2509 27TH AVE N
-----------------------------------------------------
City | MINNEAPOLIS
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55411-1001
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 651-403-3585
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | 19085
-----------------------------------------------------
License Number State | MN
-----------------------------------------------------