Healthcare Provider Details

I. General information

NPI: 1619471398
Provider Name (Legal Business Name): BURGUNDI HEBERT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/19/2018
Last Update Date: 03/19/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1011 W BROADWAY AVE STE 110
MINNEAPOLIS MN
55411-2531
US

IV. Provider business mailing address

1011 W BROADWAY AVE STE 110
MINNEAPOLIS MN
55411-2531
US

V. Phone/Fax

Practice location:
  • Phone: 612-886-4218
  • Fax:
Mailing address:
  • Phone: 612-886-4218
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: