Provider Demographics
NPI:1851043731
Name:BLISS, MADILYN R
Entity Type:Individual
Prefix:
First Name:MADILYN
Middle Name:R
Last Name:BLISS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1646 NILES AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55116-1422
Mailing Address - Country:US
Mailing Address - Phone:612-999-5234
Mailing Address - Fax:
Practice Address - Street 1:7601 WAYZATA BLVD
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS PARK
Practice Address - State:MN
Practice Address - Zip Code:55426-1626
Practice Address - Country:US
Practice Address - Phone:612-223-8898
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-22
Last Update Date:2022-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty