Provider Demographics
NPI:1649564188
Name:BLUE IRIS THERAPY, PLLC
Entity type:Organization
Organization Name:BLUE IRIS THERAPY, PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER/PSYCHOTHERAPIST
Authorized Official - Prefix:DR
Authorized Official - First Name:GRANT
Authorized Official - Middle Name:D
Authorized Official - Last Name:CHIKAZAWA-NELSON
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:612-655-9776
Mailing Address - Street 1:6437 LYNDALE AVE S
Mailing Address - Street 2:SUITE 101
Mailing Address - City:RICHFIELD
Mailing Address - State:MN
Mailing Address - Zip Code:55423-1465
Mailing Address - Country:US
Mailing Address - Phone:612-455-4040
Mailing Address - Fax:612-455-4041
Practice Address - Street 1:6437 LYNDALE AVE S
Practice Address - Street 2:SUITE 101
Practice Address - City:RICHFIELD
Practice Address - State:MN
Practice Address - Zip Code:55423-1465
Practice Address - Country:US
Practice Address - Phone:612-455-4040
Practice Address - Fax:612-455-4041
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-06-01
Last Update Date:2011-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN943251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN227349918OtherMEDICA-UBH
MN540521OtherVALUE OPTIONS
MN143645OtherU-CARE
MN529100300Medicaid
MN550045 02OtherBHP
MN69B22CHOtherBC/BS