Provider Demographics
NPI:1033842398
Name:BISSONETT, RAEGAN ROSE
Entity Type:Individual
Prefix:
First Name:RAEGAN
Middle Name:ROSE
Last Name:BISSONETT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:303 1ST AVE NE STE 365
Mailing Address - Street 2:
Mailing Address - City:FARIBAULT
Mailing Address - State:MN
Mailing Address - Zip Code:55021-5297
Mailing Address - Country:US
Mailing Address - Phone:651-304-0307
Mailing Address - Fax:
Practice Address - Street 1:303 1ST AVE NE STE 365
Practice Address - Street 2:
Practice Address - City:FARIBAULT
Practice Address - State:MN
Practice Address - Zip Code:55021-5297
Practice Address - Country:US
Practice Address - Phone:651-304-0307
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-07-05
Last Update Date:2022-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2775101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
NONEOtherNONE