Provider Demographics
NPI:1609855956
Name:BOEHLKE, MARY RUTH (PSYD)
Entity Type:Individual
Prefix:DR
First Name:MARY
Middle Name:RUTH
Last Name:BOEHLKE
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17935 2ND AVE N
Mailing Address - Street 2:
Mailing Address - City:PLYMOUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55447-3486
Mailing Address - Country:US
Mailing Address - Phone:763-476-4924
Mailing Address - Fax:
Practice Address - Street 1:1660 HIGHWAY 100 S
Practice Address - Street 2:STE. 568
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55416-1529
Practice Address - Country:US
Practice Address - Phone:952-545-6800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-14
Last Update Date:2007-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNMN LP0708103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN1G186BOOtherBLUE CROSS OF MN