Healthcare Provider Details

I. General information

NPI: 1538882964
Provider Name (Legal Business Name): NATHANIEL JOHN BRUTEJCEK LPCC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/21/2022
Last Update Date: 06/04/2026
Certification Date: 06/04/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5353 WAYZATA BLVD STE 510
ST LOUIS PARK MN
55416-1340
US

IV. Provider business mailing address

5353 WAYZATA BLVD STE 510
ST LOUIS PARK MN
55416-1340
US

V. Phone/Fax

Practice location:
  • Phone: 952-254-3557
  • Fax:
Mailing address:
  • Phone: 952-254-3557
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number3488
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: