Provider Demographics
NPI:1801094982
Name:MARY R. BOEHLKE PSY.D. P.C.
Entity type:Organization
Organization Name:MARY R. BOEHLKE PSY.D. P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MARY
Authorized Official - Middle Name:
Authorized Official - Last Name:BOEHLKE
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:952-545-6800
Mailing Address - Street 1:17935 2ND AVE N
Mailing Address - Street 2:
Mailing Address - City:PLYMOUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55447-3486
Mailing Address - Country:US
Mailing Address - Phone:763-476-4924
Mailing Address - Fax:
Practice Address - Street 1:1660 HIGHWAY 100 S
Practice Address - Street 2:STE. 568
Practice Address - City:ST LOUIS PARK
Practice Address - State:MN
Practice Address - Zip Code:55416-1529
Practice Address - Country:US
Practice Address - Phone:952-545-6800
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-10
Last Update Date:2007-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNMN LP0708103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN1G182BOOtherBLUE CROSS OF MN