Provider Demographics
NPI:1093014870
Name:BRUST, ANGELA MICHELLE (LICSW)
Entity Type:Individual
Prefix:
First Name:ANGELA
Middle Name:MICHELLE
Last Name:BRUST
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:ANGELA
Other - Middle Name:MICHELLE
Other - Last Name:HOLMBERG
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LICSW
Mailing Address - Street 1:5200 WILLSON RD STE 307
Mailing Address - Street 2:
Mailing Address - City:EDINA
Mailing Address - State:MN
Mailing Address - Zip Code:55424-1344
Mailing Address - Country:US
Mailing Address - Phone:612-405-5565
Mailing Address - Fax:
Practice Address - Street 1:5200 WILLSON RD STE 307
Practice Address - Street 2:
Practice Address - City:EDINA
Practice Address - State:MN
Practice Address - Zip Code:55424-1344
Practice Address - Country:US
Practice Address - Phone:612-405-5565
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-03-20
Last Update Date:2021-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN192371041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical