Provider Demographics
NPI:1497712343
Name:BRUNNER, CAROLYN EVELYN (LICSW)
Entity Type:Individual
Prefix:MS
First Name:CAROLYN
Middle Name:EVELYN
Last Name:BRUNNER
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2235 FLORA CT
Mailing Address - Street 2:
Mailing Address - City:LINO LAKES
Mailing Address - State:MN
Mailing Address - Zip Code:55038-7731
Mailing Address - Country:US
Mailing Address - Phone:651-762-7962
Mailing Address - Fax:612-827-8916
Practice Address - Street 1:3009 HOLMES AVE
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55408-2628
Practice Address - Country:US
Practice Address - Phone:612-871-8998
Practice Address - Fax:612-827-8916
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-26
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN013451041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN62-20337OtherUNITED BEHAVIOR HEALTH
MN02188BROtherBCBS