Provider Demographics
NPI:1508471624
Name:BLEEKER, AMY BETH BUTLER
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:BETH BUTLER
Last Name:BLEEKER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:AMY
Other - Middle Name:B
Other - Last Name:BUTLER
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:1380 ARBOR ST
Mailing Address - Street 2:
Mailing Address - City:WAYZATA
Mailing Address - State:MN
Mailing Address - Zip Code:55391-9107
Mailing Address - Country:US
Mailing Address - Phone:651-231-5356
Mailing Address - Fax:
Practice Address - Street 1:13100 WAYZATA BLVD STE 200
Practice Address - Street 2:
Practice Address - City:MINNETONKA
Practice Address - State:MN
Practice Address - Zip Code:55305-1810
Practice Address - Country:US
Practice Address - Phone:952-333-4119
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-15
Last Update Date:2020-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN305805101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)