Provider Demographics
NPI:1215003231
Name:SUSAN BRUST LLC
Entity Type:Organization
Organization Name:SUSAN BRUST LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PSYCHIATRIC NURSE PRACTITIONER
Authorized Official - Prefix:
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:RENE
Authorized Official - Last Name:BRUST
Authorized Official - Suffix:
Authorized Official - Credentials:MS, RN, CNS, NP
Authorized Official - Phone:507-280-0690
Mailing Address - Street 1:3253 19TH ST NW
Mailing Address - Street 2:SUITE 1
Mailing Address - City:ROCHESTER
Mailing Address - State:MN
Mailing Address - Zip Code:55901-6786
Mailing Address - Country:US
Mailing Address - Phone:507-280-0690
Mailing Address - Fax:507-282-6659
Practice Address - Street 1:3253 19TH ST NW
Practice Address - Street 2:SUITE 1
Practice Address - City:ROCHESTER
Practice Address - State:MN
Practice Address - Zip Code:55901-6786
Practice Address - Country:US
Practice Address - Phone:507-280-0690
Practice Address - Fax:507-282-6659
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-28
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNR 130695-2261QM0850X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health