Healthcare Provider Details

I. General information

NPI: 1972171726
Provider Name (Legal Business Name): MICHAEL BROOKS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/16/2021
Last Update Date: 06/16/2021
Certification Date: 06/16/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

451 LEXINGTON PKWY N
SAINT PAUL MN
55104-4636
US

IV. Provider business mailing address

451 LEXINGTON PKWY N
SAINT PAUL MN
55104-4636
US

V. Phone/Fax

Practice location:
  • Phone: 651-280-2310
  • Fax:
Mailing address:
  • Phone: 651-280-2310
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number27527
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: