Provider Demographics
NPI:1750458899
Name:BRANDL, ROCHELLE J (PHD, LP)
Entity Type:Individual
Prefix:DR
First Name:ROCHELLE
Middle Name:J
Last Name:BRANDL
Suffix:
Gender:F
Credentials:PHD, LP
Other - Prefix:
Other - First Name:SHELLY
Other - Middle Name:J
Other - Last Name:BRANDL
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PHD, LP
Mailing Address - Street 1:6120 EARLE BROWN DR
Mailing Address - Street 2:SUITE 520
Mailing Address - City:BROOKLYN CENTER
Mailing Address - State:MN
Mailing Address - Zip Code:55430-2123
Mailing Address - Country:US
Mailing Address - Phone:763-531-0566
Mailing Address - Fax:763-531-0602
Practice Address - Street 1:6120 EARLE BROWN DR
Practice Address - Street 2:SUITE 520
Practice Address - City:BROOKLYN CENTER
Practice Address - State:MN
Practice Address - Zip Code:55430-2123
Practice Address - Country:US
Practice Address - Phone:763-531-0566
Practice Address - Fax:763-531-0602
Is Sole Proprietor?:No
Enumeration Date:2006-11-30
Last Update Date:2016-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP0466103T00000X, 103TC2200X, 103TA0400X, 103TB0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TA0400XBehavioral Health & Social Service ProvidersPsychologistAddiction (Substance Use Disorder)
No103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & Behavioral
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN096547200Medicaid
MN68002231Medicare PIN