=====================================================
General NPI Number Information
=====================================================
NPI Number | 1134933922
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | BRIAN NOLAN
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/03/2025
-----------------------------------------------------
Last Update Date | 02/03/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3760 SILVER LAKE RD NE APT 1453
-----------------------------------------------------
City | MINNEAPOLIS
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55421-4484
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 651-353-0502
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3760 SILVER LAKE RD NE APT 1453
-----------------------------------------------------
City | MINNEAPOLIS
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55421-4484
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 651-353-0502
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | 31840
-----------------------------------------------------
License Number State | MN
-----------------------------------------------------