Provider Demographics
NPI:1689171274
Name:DUVAL, BROOKE LOUISE (BS ECSE)
Entity Type:Individual
Prefix:
First Name:BROOKE
Middle Name:LOUISE
Last Name:DUVAL
Suffix:
Gender:F
Credentials:BS ECSE
Other - Prefix:
Other - First Name:BROOKE
Other - Middle Name:LOUISE
Other - Last Name:SIEGERT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:BS ECSE
Mailing Address - Street 1:P.O. BOX 190
Mailing Address - Street 2:
Mailing Address - City:HILLSBORO
Mailing Address - State:ND
Mailing Address - Zip Code:58045-0190
Mailing Address - Country:US
Mailing Address - Phone:701-636-5220
Mailing Address - Fax:701-636-5221
Practice Address - Street 1:212 W CALEDONIA AVENUE
Practice Address - Street 2:
Practice Address - City:HILLSBORO
Practice Address - State:ND
Practice Address - Zip Code:58045-0190
Practice Address - Country:US
Practice Address - Phone:701-636-5220
Practice Address - Fax:701-636-5221
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-10
Last Update Date:2024-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106S00000X
ND171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND1467934Medicaid