Healthcare Provider Details

I. General information

NPI: 1700933009
Provider Name (Legal Business Name): BRENDA M HAUGEN LICENSED SPECIALIST
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/05/2007
Last Update Date: 03/25/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2812 17TH AVE S STE E
GRAND FORKS ND
58201-4048
US

IV. Provider business mailing address

2812 17TH AVE S STE E
GRAND FORKS ND
58201-4048
US

V. Phone/Fax

Practice location:
  • Phone: 701-746-8421
  • Fax: 701-746-4719
Mailing address:
  • Phone: 701-746-8421
  • Fax: 701-746-4719

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332S00000X
TaxonomyHearing Aid Equipment
License Number2212
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: