Provider Demographics
NPI:1336775543
Name:BAKSH, RUKSANA
Entity Type:Individual
Prefix:
First Name:RUKSANA
Middle Name:
Last Name:BAKSH
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:PO BOX 11
Mailing Address - Street 2:
Mailing Address - City:CENTER CITY
Mailing Address - State:MN
Mailing Address - Zip Code:55012-0011
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:15251 PLEASANT VALLEY RD
Practice Address - Street 2:
Practice Address - City:CENTER CITY
Practice Address - State:MN
Practice Address - Zip Code:55012-9640
Practice Address - Country:US
Practice Address - Phone:844-576-0436
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-03-19
Last Update Date:2021-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY104941-011041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical