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General NPI Number Information
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NPI Number | 1245281823
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Entity Type | Individual
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Provider Name | KENT GREGORY BROCKMANN MD
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Gender | Male
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Dates
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Enumeration Date | 05/16/2006
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Last Update Date | 06/25/2013
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Provider Practice Location Address
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Address Line | 8673 EAGLE POINT BLVD
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City | LAKE ELMO
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State | MN
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Zip | 55042
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Country | US
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Telephone | 651-209-9383
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Fax | 651-209-9384
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Provider Business Mailing Address
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Address Line | 8673 EAGLE POINT BLVD
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City | LAKE ELMO
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State | MN
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Zip | 55042
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Country | US
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Telephone | 651-209-9383
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Fax | 651-209-9384
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2084P0800X
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Taxonomy Name | Psychiatry Physician
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License Number | 44519
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License Number State | MN
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Taxonomy #2
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Taxonomy Code | 261QM0801X
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Taxonomy Name | Mental Health Clinic/Center (Including Community Mental Health Center)
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License Number | 44519
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License Number State | MN
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Taxonomy #3
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Taxonomy Code | 261QM0850X
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Taxonomy Name | Adult Mental Health Clinic/Center
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License Number | 48376-20
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License Number State | WI
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Taxonomy #4
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Taxonomy Code | 261QM0855X
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Taxonomy Name | Adolescent and Children Mental Health Clinic/Center
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License Number |
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License Number State |
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