Provider Demographics
NPI:1063464824
Name:BOOSHKE MENTAL HEALTH INC.
Entity Type:Organization
Organization Name:BOOSHKE MENTAL HEALTH INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MENTAL HEALTH PROFESSIONAL
Authorized Official - Prefix:
Authorized Official - First Name:MELISSA
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:GEORGE-HUMPHREY
Authorized Official - Suffix:
Authorized Official - Credentials:LICSW
Authorized Official - Phone:218-760-2222
Mailing Address - Street 1:2201 SHANNON LN SE
Mailing Address - Street 2:
Mailing Address - City:BEMIDJI
Mailing Address - State:MN
Mailing Address - Zip Code:56601-7328
Mailing Address - Country:US
Mailing Address - Phone:218-760-2222
Mailing Address - Fax:218-444-7105
Practice Address - Street 1:522 BELTRAMI AVE NW STE 116
Practice Address - Street 2:
Practice Address - City:BEMIDJI
Practice Address - State:MN
Practice Address - Zip Code:56601-3002
Practice Address - Country:US
Practice Address - Phone:218-760-2222
Practice Address - Fax:218-444-7105
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-17
Last Update Date:2011-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN144861041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN288620100Medicaid