Provider Demographics
NPI:1760048367
Name:DUFOUR, BRIAN
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:
Last Name:DUFOUR
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2267 17TH AVE E
Mailing Address - Street 2:
Mailing Address - City:NORTH SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55109-1847
Mailing Address - Country:US
Mailing Address - Phone:651-500-0596
Mailing Address - Fax:
Practice Address - Street 1:2267 17TH AVE E
Practice Address - Street 2:
Practice Address - City:NORTH SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55109-1847
Practice Address - Country:US
Practice Address - Phone:651-500-0596
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-20
Last Update Date:2019-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN304435101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)