Healthcare Provider Details

I. General information

NPI: 1497467906
Provider Name (Legal Business Name): MEGAN RUSTAD LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: MEGAN BRADLEY

II. Dates (important events)

Enumeration Date: 12/15/2022
Last Update Date: 06/06/2026
Certification Date: 06/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1403 SILVER LAKE RD NW STE 2
NEW BRIGHTON MN
55112-9308
US

IV. Provider business mailing address

1403 SILVER LAKE RD NW STE 2
NEW BRIGHTON MN
55112-9308
US

V. Phone/Fax

Practice location:
  • Phone: 763-443-3513
  • Fax:
Mailing address:
  • Phone: 763-443-3513
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number03276
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: