Healthcare Provider Details

I. General information

NPI: 1790975928
Provider Name (Legal Business Name): STEPHANI LOUISE BRUYER M.A.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/25/2007
Last Update Date: 02/04/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1603 W OLD SHAKOPEE RD
BLOOMINGTON MN
55431-3065
US

IV. Provider business mailing address

18986 LAKE DR E
CHANHASSEN MN
55317-9348
US

V. Phone/Fax

Practice location:
  • Phone: 952-767-3680
  • Fax: 952-767-0018
Mailing address:
  • Phone: 952-474-5974
  • Fax: 952-474-3654

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License NumberLP3669
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: