Healthcare Provider Details

I. General information

NPI: 1073350849
Provider Name (Legal Business Name): BREE LYNN MEDUNA LICSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: BREANNA LYNN MEDUNA LICSW

II. Dates (important events)

Enumeration Date: 07/10/2024
Last Update Date: 10/16/2024
Certification Date: 10/16/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5555 BOONE AVE N
NEW HOPE MN
55428-3636
US

IV. Provider business mailing address

3000 AMES CROSSING RD STE 600
EAGAN MN
55121-2570
US

V. Phone/Fax

Practice location:
  • Phone: 651-774-0011
  • Fax: 651-774-0606
Mailing address:
  • Phone: 651-774-0011
  • Fax: 651-774-0606

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number20564
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: