Provider Demographics
NPI:1316000797
Name:HUSELID, ELAINE VIVIAN (MED)
Entity Type:Individual
Prefix:
First Name:ELAINE
Middle Name:VIVIAN
Last Name:HUSELID
Suffix:
Gender:F
Credentials:MED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1641 W 140TH ST
Mailing Address - Street 2:
Mailing Address - City:BURNSVILLE
Mailing Address - State:MN
Mailing Address - Zip Code:55337-4418
Mailing Address - Country:US
Mailing Address - Phone:952-797-3169
Mailing Address - Fax:952-426-1725
Practice Address - Street 1:14579 GRAND AVE
Practice Address - Street 2:SUITE 200
Practice Address - City:BURNSVILLE
Practice Address - State:MN
Practice Address - Zip Code:55306-5702
Practice Address - Country:US
Practice Address - Phone:952-797-3169
Practice Address - Fax:952-426-1725
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-18
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN3047103TC1900X
MN65421041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
Not Answered1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN01020012OtherBHP PROVIDER #
MN14D35HU AND 14D36HUOtherBCBS PROVIDER #
MN62-37268OtherUBH PROVIDER #
MNHP 28356OtherHEALTH PARTNER'S PROVIDER