Provider Demographics
NPI:1023013174
Name:BRINK, DOUGLAS ALAN (LISW, LMFT)
Entity Type:Individual
Prefix:MR
First Name:DOUGLAS
Middle Name:ALAN
Last Name:BRINK
Suffix:
Gender:M
Credentials:LISW, LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:202 1ST ST SE
Mailing Address - Street 2:SUITE 107
Mailing Address - City:MASON CITY
Mailing Address - State:IA
Mailing Address - Zip Code:50401-3946
Mailing Address - Country:US
Mailing Address - Phone:641-423-3778
Mailing Address - Fax:641-423-3881
Practice Address - Street 1:202 1ST ST SE
Practice Address - Street 2:SUITE 107
Practice Address - City:MASON CITY
Practice Address - State:IA
Practice Address - Zip Code:50401-3946
Practice Address - Country:US
Practice Address - Phone:641-423-3778
Practice Address - Fax:641-423-3881
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-16
Last Update Date:2013-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA058991041C0700X
MN0378106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0446336Medicaid
IA72639OtherWELLMARK BLUE CROSS BLUE SHIELD
IAIB1125Medicare PIN