Basic Information
| Provider Information | |||||||||
| NPI: | 1457370256 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | EISENMENGER | ||||||||
| FirstName: | BRUCE | ||||||||
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| Credential: | M.A., LP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7066 STILLWATER BLVD N | ||||||||
| Address2: | |||||||||
| City: | OAKDALE | ||||||||
| State: | MN | ||||||||
| PostalCode: | 551283937 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6517775222 | ||||||||
| FaxNumber: | 6512515111 | ||||||||
| Practice Location | |||||||||
| Address1: | 1751 COUNTY ROAD B W STE 100 | ||||||||
| Address2: | |||||||||
| City: | ROSEVILLE | ||||||||
| State: | MN | ||||||||
| PostalCode: | 551134037 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6512556954 | ||||||||
| FaxNumber: | 6517568914 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/19/2006 | ||||||||
| LastUpdateDate: | 10/19/2017 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103T00000X | 1882 | MN | Y | Behavioral Health & Social Service Providers | Psychologist |
ID Information
| ID | Type | State | Issuer | Description | 32Q54EI | 01 | MN | BCBS | OTHER | 106264 | 01 | MN | UC | OTHER | 1015029 | 01 | MN | P1 | OTHER | 133865 | 01 | MN | CP | OTHER | 18510 | 01 | MN | HP | OTHER | 62-01186 | 01 | MN | UBH | OTHER | 729325900 | 05 | MN | MEDICAID |