Provider Demographics
NPI:1457379026
Name:CLOSE, RICHARD EDWIN (DMIN, MA,LICSW, LMFT)
Entity Type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:EDWIN
Last Name:CLOSE
Suffix:
Gender:M
Credentials:DMIN, MA,LICSW, LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3450 OLEARY LN
Mailing Address - Street 2:
Mailing Address - City:EAGAN
Mailing Address - State:MN
Mailing Address - Zip Code:55123-2340
Mailing Address - Country:US
Mailing Address - Phone:651-454-0114
Mailing Address - Fax:651-454-3492
Practice Address - Street 1:3450 OLEARY LN
Practice Address - Street 2:
Practice Address - City:EAGAN
Practice Address - State:MN
Practice Address - Zip Code:55123-2340
Practice Address - Country:US
Practice Address - Phone:651-454-0114
Practice Address - Fax:651-454-3492
Is Sole Proprietor?:No
Enumeration Date:2006-07-18
Last Update Date:2018-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN0067106H00000X
MN077341041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN636357100Medicaid