Healthcare Provider Details

I. General information

NPI: 1669992186
Provider Name (Legal Business Name): STEPHANIE BRUSS PSY.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/26/2017
Last Update Date: 02/16/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

821 RAYMOND AVE # 130C
SAINT PAUL MN
55114-1503
US

IV. Provider business mailing address

821 RAYMOND AVE # 130C
SAINT PAUL MN
55114-1503
US

V. Phone/Fax

Practice location:
  • Phone: 612-440-6545
  • Fax:
Mailing address:
  • Phone: 612-440-6545
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberLP5821
License Number StateMN
# 2
Primary TaxonomyY
Taxonomy Code103TF0200X
TaxonomyForensic Psychologist
License NumberLP5821
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: