Provider Demographics
NPI:1619553559
Name:BRUA, NICHOLE MARIE
Entity Type:Individual
Prefix:
First Name:NICHOLE
Middle Name:MARIE
Last Name:BRUA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7010 HIGHWAY 7
Mailing Address - Street 2:
Mailing Address - City:ST LOUIS PARK
Mailing Address - State:MN
Mailing Address - Zip Code:55426-4223
Mailing Address - Country:US
Mailing Address - Phone:952-814-0207
Mailing Address - Fax:
Practice Address - Street 1:7010 HIGHWAY 7
Practice Address - Street 2:
Practice Address - City:ST LOUIS PARK
Practice Address - State:MN
Practice Address - Zip Code:55426-4223
Practice Address - Country:US
Practice Address - Phone:952-814-0207
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-03-22
Last Update Date:2021-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician