Provider Demographics
NPI:1033294962
Name:GARRETT-AKINSANYA, BRAVADA MAE (PHD)
Entity Type:Individual
Prefix:DR
First Name:BRAVADA
Middle Name:MAE
Last Name:GARRETT-AKINSANYA
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:1219 MARQUETTE AVE STE 80
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55403-2489
Mailing Address - Country:US
Mailing Address - Phone:612-338-9012
Mailing Address - Fax:612-338-9020
Practice Address - Street 1:2100 PLYMOUTH AVE N STE 245
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55411-3675
Practice Address - Country:US
Practice Address - Phone:612-302-3140
Practice Address - Fax:612-436-5412
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MNLP4105103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN426S3GAOtherBLUE CROSS BLUE SHIELD
MNHP29938OtherHEALTHPARTNERS
MN6168492OtherUNITED BEHAVIORAL HEALTH
MN239323900Medicaid