Provider Demographics
NPI:1295497055
Name:EIDSMO, SIRI TS
Entity type:Individual
Prefix:
First Name:SIRI
Middle Name:TS
Last Name:EIDSMO
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 1:13579 BERKSHIRE LN
Mailing Address - Street 2:
Mailing Address - City:EDEN PRAIRIE
Mailing Address - State:MN
Mailing Address - Zip Code:55347-1702
Mailing Address - Country:US
Mailing Address - Phone:218-341-6835
Mailing Address - Fax:
Practice Address - Street 1:2118 BLAISDELL AVE
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55404-2415
Practice Address - Country:US
Practice Address - Phone:651-201-2758
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-10-08
Last Update Date:2021-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN306131101YA0400X
MN30140104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)