Healthcare Provider Details

I. General information

NPI: 1710695440
Provider Name (Legal Business Name): BRENNA MUNOZ
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/10/2022
Last Update Date: 12/19/2022
Certification Date: 12/19/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2215 E LAKE ST
MINNEAPOLIS MN
55407-4385
US

IV. Provider business mailing address

2215 E LAKE ST
MINNEAPOLIS MN
55407-4385
US

V. Phone/Fax

Practice location:
  • Phone: 612-596-9438
  • Fax:
Mailing address:
  • Phone: 612-596-9438
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number306547
License Number StateMN
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number27429
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: