Provider Demographics
NPI:1376534214
Name:DREW, DOUGLAS ALAN (MA, LICSW)
Entity Type:Individual
Prefix:
First Name:DOUGLAS
Middle Name:ALAN
Last Name:DREW
Suffix:
Gender:M
Credentials:MA, LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14701 HARPERS ST NE
Mailing Address - Street 2:
Mailing Address - City:HAM LAKE
Mailing Address - State:MN
Mailing Address - Zip Code:55304-6428
Mailing Address - Country:US
Mailing Address - Phone:763-413-2829
Mailing Address - Fax:763-413-5225
Practice Address - Street 1:10190 BALTIMORE ST NE
Practice Address - Street 2:SUITE 110
Practice Address - City:BLAINE
Practice Address - State:MN
Practice Address - Zip Code:55449-5056
Practice Address - Country:US
Practice Address - Phone:763-755-7612
Practice Address - Fax:763-775-2048
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN79981041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN141257400Medicaid
MN20-4908451OtherEIN
MN20-4908451OtherEIN