Healthcare Provider Details

I. General information

NPI: 1134851710
Provider Name (Legal Business Name): MICHAEL T BROOKS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/30/2022
Last Update Date: 06/30/2022
Certification Date: 06/30/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2100 EMERSON AVE N
MINNEAPOLIS MN
55411-2512
US

IV. Provider business mailing address

6937 W PALMER LAKE DR
BROOKLYN CENTER MN
55429-4201
US

V. Phone/Fax

Practice location:
  • Phone: 612-272-5718
  • Fax:
Mailing address:
  • Phone: 612-272-5718
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MICHAEL BROOKS
Title or Position: CEO
Credential:
Phone: 612-272-5718