Provider Demographics
NPI:1497072797
Name:BREKKE, NORMAN
Entity Type:Individual
Prefix:MR
First Name:NORMAN
Middle Name:
Last Name:BREKKE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1221 W LAKE ST
Mailing Address - Street 2:SUITE 109
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55408-3397
Mailing Address - Country:US
Mailing Address - Phone:612-871-3330
Mailing Address - Fax:612-871-3331
Practice Address - Street 1:1221 W LAKE ST
Practice Address - Street 2:SUITE 109
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55408-3397
Practice Address - Country:US
Practice Address - Phone:612-871-3330
Practice Address - Fax:612-871-3331
Is Sole Proprietor?:Yes
Enumeration Date:2010-04-26
Last Update Date:2010-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXMT109053225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist