MEDICARE: BRIAN DUFOUR

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	101YA0400X	Addiction (Substance Use Disorder) Counselor	304435	MN

General Provider Information

NPI Number	:	1760048367
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BRIAN DUFOUR

Provider Business Mailing Address
First Line	:	2267 17TH AVE E
Second Line	:
City	:	NORTH SAINT PAUL
State	:	MN
Zip	:	55109-1847
Country	:	US
Telephone Number	:	651-500-0596
Fax Number	:

Provider Business Practice Location Address
First Line	:	2267 17TH AVE E
Second Line	:
City	:	NORTH SAINT PAUL
State	:	MN
Zip	:	55109-1847
Country	:	US
Telephone Number	:	651-500-0596
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/20/2019
Last Update Date	:	05/20/2019

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Directions to “ BRIAN DUFOUR ” Practice Location

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