Provider Demographics
NPI:1578637534
Name:BLONIGEN, KEVIN H (MA, LP)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:H
Last Name:BLONIGEN
Suffix:
Gender:M
Credentials:MA, LP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5100 THIMSEN AVE
Mailing Address - Street 2:SUITE 130
Mailing Address - City:MINNETONKA
Mailing Address - State:MN
Mailing Address - Zip Code:55345-4108
Mailing Address - Country:US
Mailing Address - Phone:612-716-7159
Mailing Address - Fax:952-474-4025
Practice Address - Street 1:5100 THIMSEN AVE
Practice Address - Street 2:SUITE 130
Practice Address - City:MINNETONKA
Practice Address - State:MN
Practice Address - Zip Code:55345-4108
Practice Address - Country:US
Practice Address - Phone:612-716-7159
Practice Address - Fax:952-474-4025
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP3981103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist