Provider Demographics
NPI:1326169921
Name:BRUSTAD KENNEDY, LAURIE ANN (PHD)
Entity Type:Individual
Prefix:DR
First Name:LAURIE
Middle Name:ANN
Last Name:BRUSTAD KENNEDY
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:600 DEMERS AVE
Mailing Address - Street 2:SUITE 404
Mailing Address - City:GRAND FORKS
Mailing Address - State:ND
Mailing Address - Zip Code:58201-4599
Mailing Address - Country:US
Mailing Address - Phone:701-746-4400
Mailing Address - Fax:701-746-6034
Practice Address - Street 1:600 DEMERS AVE
Practice Address - Street 2:SUITE 404
Practice Address - City:GRAND FORKS
Practice Address - State:ND
Practice Address - Zip Code:58201-4599
Practice Address - Country:US
Practice Address - Phone:701-746-4400
Practice Address - Fax:701-746-6034
Is Sole Proprietor?:No
Enumeration Date:2007-04-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND222103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
088174OtherVALUE OPTIONS
NDBRU21835OtherBCBSND
HP1672OtherHEALTH PARTNERS
ND11915Medicaid
MN308J3BROtherBCBSMN
MN308J3BROtherBLUE PLUS
204771047933OtherPREFERRED ONE
5721265OtherFIRST HEALTH
A002OtherTRICARE
NDBRU21835OtherBCBSND
A002OtherTRICARE