Provider Demographics
NPI:1346819307
Name:BEWELL PSYCHOTHERAPY PLLC
Entity Type:Organization
Organization Name:BEWELL PSYCHOTHERAPY PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MD OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ROSS
Authorized Official - Middle Name:ELLIOT
Authorized Official - Last Name:GUBRUD
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:612-421-3187
Mailing Address - Street 1:3501 XENIUM LN N APT 123
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55441-2222
Mailing Address - Country:US
Mailing Address - Phone:612-421-3187
Mailing Address - Fax:612-421-3183
Practice Address - Street 1:1821 UNIVERSITY AVE W STE 461-9
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55104-2801
Practice Address - Country:US
Practice Address - Phone:612-421-3178
Practice Address - Fax:612-421-3183
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-06-23
Last Update Date:2021-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounselingGroup - Multi-Specialty
No103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Multi-Specialty