Provider Demographics
NPI:1760837082
Name:PEARSON-BREVIK, KATHRYN
Entity Type:Individual
Prefix:
First Name:KATHRYN
Middle Name:
Last Name:PEARSON-BREVIK
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 1:6483 HERITAGE TRL
Mailing Address - Street 2:
Mailing Address - City:GILBERT
Mailing Address - State:MN
Mailing Address - Zip Code:55741-8029
Mailing Address - Country:US
Mailing Address - Phone:218-865-7021
Mailing Address - Fax:
Practice Address - Street 1:6483 HERITAGE TRL
Practice Address - Street 2:
Practice Address - City:GILBERT
Practice Address - State:MN
Practice Address - Zip Code:55741-8029
Practice Address - Country:US
Practice Address - Phone:218-865-7021
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-04-25
Last Update Date:2016-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1072919-2-HCBS302F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302F00000XManaged Care OrganizationsExclusive Provider Organization