Healthcare Provider Details

I. General information

NPI: 1356661607
Provider Name (Legal Business Name): BONNIE IRENE BRUNETTE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: BONNIE IRENE FRIES

II. Dates (important events)

Enumeration Date: 06/09/2010
Last Update Date: 07/25/2023
Certification Date: 07/25/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1100 GLENWOOD AVE
MINNEAPOLIS MN
55405-1430
US

IV. Provider business mailing address

1100 GLENWOOD AVE
MINNEAPOLIS MN
55405-1430
US

V. Phone/Fax

Practice location:
  • Phone: 612-871-1454
  • Fax:
Mailing address:
  • Phone: 612-871-1454
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number149010796
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: