Provider Demographics
NPI:1770569907
Name:BOBBY, JOEL ANTHONY (MSW LICSW)
Entity type:Individual
Prefix:
First Name:JOEL
Middle Name:ANTHONY
Last Name:BOBBY
Suffix:
Gender:M
Credentials:MSW LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1000 1ST DR NW
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:MN
Mailing Address - Zip Code:55912-2941
Mailing Address - Country:US
Mailing Address - Phone:507-434-1092
Mailing Address - Fax:507-434-1477
Practice Address - Street 1:1000 1ST DR NW
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:MN
Practice Address - Zip Code:55912-2941
Practice Address - Country:US
Practice Address - Phone:507-434-1092
Practice Address - Fax:507-434-1477
Is Sole Proprietor?:No
Enumeration Date:2005-12-20
Last Update Date:2020-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN172191041C0700X
MNLP172191041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN714434200Medicaid
MN714434200Medicaid