Provider Demographics
NPI:1336234624
Name:KOHLHASE, BRUCE ALLAN (MA, LP)
Entity type:Individual
Prefix:MR
First Name:BRUCE
Middle Name:ALLAN
Last Name:KOHLHASE
Suffix:
Gender:M
Credentials:MA, LP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4826 CHICAGO AVE. S.
Mailing Address - Street 2:SUITE 104
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55417-1055
Mailing Address - Country:US
Mailing Address - Phone:612-823-1507
Mailing Address - Fax:
Practice Address - Street 1:4826 CHICAGO AVE. S.
Practice Address - Street 2:SUITE 104
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55417-1055
Practice Address - Country:US
Practice Address - Phone:612-823-1507
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-04
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP 1960103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN0G337KOOtherBLUE CROSS/BLUE SHIELD
MN62-68428OtherMEDICA-UBH NUMBER