Provider Demographics
NPI:1730542572
Name:IRIS REPRODUCTIVE PSYCHIATRIC CLINIC
Entity type:Organization
Organization Name:IRIS REPRODUCTIVE PSYCHIATRIC CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/OPERATER
Authorized Official - Prefix:DR
Authorized Official - First Name:SAMANTHA
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:HUGUELET
Authorized Official - Suffix:
Authorized Official - Credentials:DNP APRN CNS
Authorized Official - Phone:860-406-4747
Mailing Address - Street 1:1500 MCANDREWS RD W
Mailing Address - Street 2:227
Mailing Address - City:BURNSVILLE
Mailing Address - State:MN
Mailing Address - Zip Code:55337-4432
Mailing Address - Country:US
Mailing Address - Phone:860-406-4747
Mailing Address - Fax:612-437-4759
Practice Address - Street 1:1500 MCANDREWS ROAD W
Practice Address - Street 2:STE 227
Practice Address - City:BURNSVILLE
Practice Address - State:MN
Practice Address - Zip Code:55337
Practice Address - Country:US
Practice Address - Phone:860-406-4747
Practice Address - Fax:612-437-4759
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-03-30
Last Update Date:2016-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNR134588-7364SP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes364SP0808XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistPsychiatric/Mental HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN168946100Medicaid
MN890000344Medicare Oscar/Certification
MNP70130Medicare UPIN