Provider Demographics
NPI:1598166100
Name:BRUMBAUGH, MORGAN
Entity Type:Individual
Prefix:
First Name:MORGAN
Middle Name:
Last Name:BRUMBAUGH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MORGAN
Other - Middle Name:
Other - Last Name:LACEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:14000 NORTHDALE BLVD STE I
Mailing Address - Street 2:
Mailing Address - City:ROGERS
Mailing Address - State:MN
Mailing Address - Zip Code:55374-4663
Mailing Address - Country:US
Mailing Address - Phone:637-575-8086
Mailing Address - Fax:
Practice Address - Street 1:14000 NORTHDALE BLVD STE I
Practice Address - Street 2:
Practice Address - City:ROGERS
Practice Address - State:MN
Practice Address - Zip Code:55374-4663
Practice Address - Country:US
Practice Address - Phone:763-575-8086
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-09-15
Last Update Date:2021-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
MN3303106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program