MEDICARE: MS. REBECCA LYNN PRUST LICSW

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker	17680	MN

General Provider Information

NPI Number	:	1770881088
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. REBECCA LYNN PRUST LICSW

Provider Business Mailing Address
First Line	:	1800 CHICAGO AVE
Second Line	:
City	:	MINNEAPOLIS
State	:	MN
Zip	:	55404-1901
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1800 CHICAGO AVE
Second Line	:
City	:	MINNEAPOLIS
State	:	MN
Zip	:	55404-1901
Country	:	US
Telephone Number	:	612-599-5420
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/10/2011
Last Update Date	:	12/13/2011

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