Provider Demographics
NPI:1184659716
Name:BLISSENBACH, LOUISE J (LICSW)
Entity Type:Individual
Prefix:
First Name:LOUISE
Middle Name:J
Last Name:BLISSENBACH
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:407 PROSPECT ST SE
Mailing Address - Street 2:
Mailing Address - City:CHATFIELD
Mailing Address - State:MN
Mailing Address - Zip Code:55923-1412
Mailing Address - Country:US
Mailing Address - Phone:507-867-4056
Mailing Address - Fax:
Practice Address - Street 1:124 ELTON HILLS LN NW
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:MN
Practice Address - Zip Code:55901-3567
Practice Address - Country:US
Practice Address - Phone:507-282-1009
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN12451041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN00468620Medicaid