Healthcare Provider Details

I. General information

NPI: 1306010053
Provider Name (Legal Business Name): DONNA M. BRENGMAN M.S.W., LICSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/14/2008
Last Update Date: 03/12/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13045 FALCON DR STE 100
BAXTER MN
56425-4201
US

IV. Provider business mailing address

1900 SILVER LAKE RD NW
NEW BRIGHTON MN
55112-1786
US

V. Phone/Fax

Practice location:
  • Phone: 218-829-9307
  • Fax: 218-829-7649
Mailing address:
  • Phone: 651-628-9566
  • Fax: 651-628-0411

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number14744
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: