Provider Demographics
NPI:1649461344
Name:BLOOMING PRAIRIE ASSESSMENT & THERAPY CENTER P.C.
Entity type:Organization
Organization Name:BLOOMING PRAIRIE ASSESSMENT & THERAPY CENTER P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LICENSED PSYCHOLOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:SARA
Authorized Official - Middle Name:K
Authorized Official - Last Name:KENNEY
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:701-662-8255
Mailing Address - Street 1:211 4TH ST NE
Mailing Address - Street 2:STE 4
Mailing Address - City:DEVILS LAKE
Mailing Address - State:ND
Mailing Address - Zip Code:58301-2479
Mailing Address - Country:US
Mailing Address - Phone:701-662-8255
Mailing Address - Fax:701-662-1739
Practice Address - Street 1:211 4TH ST NE
Practice Address - Street 2:STE 4
Practice Address - City:DEVILS LAKE
Practice Address - State:ND
Practice Address - Zip Code:58301-2479
Practice Address - Country:US
Practice Address - Phone:701-662-8255
Practice Address - Fax:701-662-1739
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-07
Last Update Date:2013-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND464103TC0700X
ND43701041C0700X
ND377103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Multi-Specialty
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND6978-001OtherBCBS OF ND
ND600066OtherVALUE OPTIONS
ND14303Medicaid
NDN712747Medicare PIN