Healthcare Provider Details

I. General information

NPI: 1235397381
Provider Name (Legal Business Name): BRENDA JEAN HANSEN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: BRENDA JEAN PETERSON

II. Dates (important events)

Enumeration Date: 05/27/2008
Last Update Date: 05/27/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

425 6TH AVENUE WEST
FLOODWOOD MN
55736
US

IV. Provider business mailing address

9021 EKLUND RD
BROOKSTON MN
55711-8005
US

V. Phone/Fax

Practice location:
  • Phone: 218-390-6167
  • Fax:
Mailing address:
  • Phone: 218-453-5684
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD1600X
TaxonomyDevelopmental Disabilities Clinic/Center
License Number830452
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: