Healthcare Provider Details

I. General information

NPI: 1245732049
Provider Name (Legal Business Name): HEIDI KIRSTEN BRUDER
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/07/2018
Last Update Date: 02/03/2022
Certification Date: 01/27/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

156 30TH ST NE
BEMIDJI MN
56601-5660
US

IV. Provider business mailing address

483 SEED FARM RD
SACATON AZ
85147
US

V. Phone/Fax

Practice location:
  • Phone: 480-431-1589
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number28455
License Number StateMN
# 2
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberLMSW-11285
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: