Provider Demographics
NPI:1275656431
Name:BRUTLAG, GWEN (MS, LP)
Entity Type:Individual
Prefix:
First Name:GWEN
Middle Name:
Last Name:BRUTLAG
Suffix:
Gender:F
Credentials:MS, LP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:220 W WASHINGTON AVE
Mailing Address - Street 2:WELLS FARGO BANK BUILDING, SUITE 204
Mailing Address - City:FERGUS FALLS
Mailing Address - State:MN
Mailing Address - Zip Code:56537-2569
Mailing Address - Country:US
Mailing Address - Phone:218-739-8761
Mailing Address - Fax:218-739-8581
Practice Address - Street 1:220 W WASHINGTON AVE
Practice Address - Street 2:WELLS FARGO BANK BUILDING, SUITE 204
Practice Address - City:FERGUS FALLS
Practice Address - State:MN
Practice Address - Zip Code:56537-2569
Practice Address - Country:US
Practice Address - Phone:218-739-8761
Practice Address - Fax:218-739-8581
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP 1204103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
1991028OtherFED ID NUMBER
MNLP 1204OtherLISENCE NUMBER