Healthcare Provider Details

I. General information

NPI: 1346692886
Provider Name (Legal Business Name): BRENNA LYN MACDONALD MSW, LICSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/08/2016
Last Update Date: 07/08/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

220 RAILROAD ST SE
PINE CITY MN
55063-1540
US

IV. Provider business mailing address

220 RAILROAD ST SE
PINE CITY MN
55063-1540
US

V. Phone/Fax

Practice location:
  • Phone: 320-629-7600
  • Fax: 651-925-0071
Mailing address:
  • Phone: 320-629-7600
  • Fax: 651-925-0071

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number21689
License Number StateMN

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: