Provider Demographics
NPI:1831704816
Name:BONNIE BRAE PSYCHOTHERAPY LLC
Entity type:Organization
Organization Name:BONNIE BRAE PSYCHOTHERAPY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:SCHAEFFER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:612-618-6268
Mailing Address - Street 1:821 RAYMOND AVE STE 440
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55114-1525
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:821 RAYMOND AVE STE 440
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55114-1525
Practice Address - Country:US
Practice Address - Phone:612-552-7023
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-09-15
Last Update Date:2020-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN1336422161Medicaid