Provider Demographics
NPI:1629757430
Name:BRAULT, ABAGAEL JO (MA)
Entity type:Individual
Prefix:
First Name:ABAGAEL
Middle Name:JO
Last Name:BRAULT
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1900 SILVER LAKE RD NW STE 110
Mailing Address - Street 2:
Mailing Address - City:NEW BRIGHTON
Mailing Address - State:MN
Mailing Address - Zip Code:55112-1789
Mailing Address - Country:US
Mailing Address - Phone:651-628-9566
Mailing Address - Fax:
Practice Address - Street 1:5353 WAYZATA BLVD STE 510
Practice Address - Street 2:
Practice Address - City:ST LOUIS PARK
Practice Address - State:MN
Practice Address - Zip Code:55416-1340
Practice Address - Country:US
Practice Address - Phone:952-254-3557
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-07-18
Last Update Date:2025-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN03960101YM0800X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program