Provider Demographics
NPI:1790975928
Name:BRUYER, STEPHANI LOUISE (MA)
Entity Type:Individual
Prefix:MS
First Name:STEPHANI
Middle Name:LOUISE
Last Name:BRUYER
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 1:18986 LAKE DR E
Mailing Address - Street 2:
Mailing Address - City:CHANHASSEN
Mailing Address - State:MN
Mailing Address - Zip Code:55317-9348
Mailing Address - Country:US
Mailing Address - Phone:952-474-5974
Mailing Address - Fax:952-474-3654
Practice Address - Street 1:1603 W OLD SHAKOPEE RD
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:MN
Practice Address - Zip Code:55431-3065
Practice Address - Country:US
Practice Address - Phone:952-767-3680
Practice Address - Fax:952-767-0018
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-25
Last Update Date:2014-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP3669103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist