Provider Demographics
NPI:1285841072
Name:BLUE IRIS CENTER FOR THERAPEUTIC SERVICES
Entity Type:Organization
Organization Name:BLUE IRIS CENTER FOR THERAPEUTIC SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER THERAPIST
Authorized Official - Prefix:DR
Authorized Official - First Name:GRANT
Authorized Official - Middle Name:D
Authorized Official - Last Name:CHIKAZAWANELSON
Authorized Official - Suffix:
Authorized Official - Credentials:PHD, LMFT
Authorized Official - Phone:612-455-4040
Mailing Address - Street 1:6607 18TH AVE S
Mailing Address - Street 2:SUITE 201
Mailing Address - City:RICHFIELD
Mailing Address - State:MN
Mailing Address - Zip Code:55423-2784
Mailing Address - Country:US
Mailing Address - Phone:612-455-4040
Mailing Address - Fax:612-455-4041
Practice Address - Street 1:6607 18TH AVE S
Practice Address - Street 2:SUITE 201
Practice Address - City:RICHFIELD
Practice Address - State:MN
Practice Address - Zip Code:55423-2784
Practice Address - Country:US
Practice Address - Phone:612-455-4040
Practice Address - Fax:612-455-4041
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-17
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN0943251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN69B21CHOtherBLUE CROSS BLUE SHIELD
MN=========OtherWAUSAU BENEFITS
MN69B21CHOtherBLUE CROSS BLUE SHIELD
MN=========OtherUBH