Provider Demographics
NPI:1053824748
Name:BROBERG, KAYLIE
Entity Type:Individual
Prefix:
First Name:KAYLIE
Middle Name:
Last Name:BROBERG
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9800 SHELARD PKWY STE 115
Mailing Address - Street 2:
Mailing Address - City:PLYMOUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55441-6411
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:9800 SHELARD PKWY STE 115
Practice Address - Street 2:
Practice Address - City:PLYMOUTH
Practice Address - State:MN
Practice Address - Zip Code:55441-6411
Practice Address - Country:US
Practice Address - Phone:651-447-7507
Practice Address - Fax:763-432-6001
Is Sole Proprietor?:No
Enumeration Date:2017-11-16
Last Update Date:2021-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN3775106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist