Healthcare Provider Details

I. General information

NPI: 1083523625
Provider Name (Legal Business Name): BRIAN FRUCHTMAN LMSW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/01/2026
Last Update Date: 09/01/2026
Certification Date: 09/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2196 LOWER AFTON RD E APT 112
SAINT PAUL MN
55119-5034
US

IV. Provider business mailing address

2196 LOWER AFTON RD E APT 112
SAINT PAUL MN
55119-5034
US

V. Phone/Fax

Practice location:
  • Phone: 612-389-6865
  • Fax:
Mailing address:
  • Phone: 612-475-2698
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number118316
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: