Provider Demographics
NPI:1346325198
Name:BRULEY, CHARLENE P (LICSW)
Entity Type:Individual
Prefix:
First Name:CHARLENE
Middle Name:P
Last Name:BRULEY
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1705 4TH AVE NW
Mailing Address - Street 2:
Mailing Address - City:MINOT
Mailing Address - State:ND
Mailing Address - Zip Code:58703-2912
Mailing Address - Country:US
Mailing Address - Phone:701-839-0474
Mailing Address - Fax:701-839-0713
Practice Address - Street 1:1705 4TH AVE NW
Practice Address - Street 2:
Practice Address - City:MINOT
Practice Address - State:ND
Practice Address - Zip Code:58703-2912
Practice Address - Country:US
Practice Address - Phone:701-839-0474
Practice Address - Fax:701-839-0713
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND37641041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND19159Medicaid
ND711888Medicare ID - Type Unspecified