Healthcare Provider Details

I. General information

NPI: 1881558781
Provider Name (Legal Business Name): ELLEN KRISTINE BROKL LICSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/15/2025
Last Update Date: 12/15/2025
Certification Date: 12/15/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2525 CHICAGO AVE
MINNEAPOLIS MN
55404-4518
US

IV. Provider business mailing address

6244 2ND AVE S
RICHFIELD MN
55423-1617
US

V. Phone/Fax

Practice location:
  • Phone: 612-813-7157
  • Fax:
Mailing address:
  • Phone: 612-269-7305
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number32915
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: