Provider Demographics
NPI:1063089134
Name:BOEHNKE, GRACE ELIZABETH LOUISE (LADC)
Entity type:Individual
Prefix:
First Name:GRACE
Middle Name:ELIZABETH LOUISE
Last Name:BOEHNKE
Suffix:
Gender:F
Credentials:LADC
Other - Prefix:
Other - First Name:GRACE
Other - Middle Name:ELIZABETH LOUISE
Other - Last Name:HOGGARD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LADC
Mailing Address - Street 1:126 8TH ST NE
Mailing Address - Street 2:
Mailing Address - City:BYRON
Mailing Address - State:MN
Mailing Address - Zip Code:55920-1440
Mailing Address - Country:US
Mailing Address - Phone:651-829-0191
Mailing Address - Fax:
Practice Address - Street 1:604 5TH ST SW
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:MN
Practice Address - Zip Code:55902-3256
Practice Address - Country:US
Practice Address - Phone:507-282-2500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-08
Last Update Date:2021-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN304271101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)