Healthcare Provider Details

I. General information

NPI: 1295712495
Provider Name (Legal Business Name): MICHELLE A BROUILLETTE PHD, LP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/28/2005
Last Update Date: 07/13/2020
Certification Date: 07/13/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11990 PORTLAND AVE
BURNSVILLE MN
55337-1516
US

IV. Provider business mailing address

11990 PORTLAND AVE
BURNSVILLE MN
55337-1516
US

V. Phone/Fax

Practice location:
  • Phone: 612-462-7053
  • Fax: 952-479-7896
Mailing address:
  • Phone: 952-435-8814
  • Fax: 952-435-7705

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License NumberLP2929
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: