Healthcare Provider Details

I. General information

NPI: 1215003231
Provider Name (Legal Business Name): SUSAN BRUST LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/28/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3253 19TH ST NW SUITE 1
ROCHESTER MN
55901-6786
US

IV. Provider business mailing address

3253 19TH ST NW SUITE 1
ROCHESTER MN
55901-6786
US

V. Phone/Fax

Practice location:
  • Phone: 507-280-0690
  • Fax: 507-282-6659
Mailing address:
  • Phone: 507-280-0690
  • Fax: 507-282-6659

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License NumberR 130695-2
License Number StateMN

VIII. Authorized Official

Name: SUSAN RENE BRUST
Title or Position: PSYCHIATRIC NURSE PRACTITIONER
Credential: MS, RN, CNS, NP
Phone: 507-280-0690