MEDICARE: BRENNA PHAM LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	235Z00000X	Speech-Language Pathologist

General Provider Information

NPI Number	:	1710520598
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BRENNA PHAM LLC

Provider Business Mailing Address
First Line	:	4250 BROWNDALE AVE
Second Line	:
City	:	SAINT LOUIS PARK
State	:	MN
Zip	:	55416-3220
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	4250 BROWNDALE AVE
Second Line	:
City	:	SAINT LOUIS PARK
State	:	MN
Zip	:	55416-3220
Country	:	US
Telephone Number	:	612-965-5732
Fax Number	:

Authorized Official
Title or Position	:	SPEECH-LANGUAGE PATHOLOGIST
Name	:	BRENNA PHAM
Credential	:	MA, CCC-SLP
Telephone Number	:	612-965-5732

Provider Enumeration Date	:	10/23/2019
Last Update Date	:	11/06/2019

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Directions to “BRENNA PHAM LLC ” Practice Location

Language	Start Address	Practice Location

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