Provider Demographics
NPI:1457316812
Name:BRUNETTI, CHERI L (PHD, LP)
Entity Type:Individual
Prefix:
First Name:CHERI
Middle Name:L
Last Name:BRUNETTI
Suffix:
Gender:F
Credentials:PHD, LP
Other - Prefix:
Other - First Name:CHERI
Other - Middle Name:L
Other - Last Name:HEXUM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PHD, LP
Mailing Address - Street 1:21308 JOHN MILLESS DR
Mailing Address - Street 2:SUITE 101B
Mailing Address - City:ROGERS
Mailing Address - State:MN
Mailing Address - Zip Code:55374-4708
Mailing Address - Country:US
Mailing Address - Phone:763-428-4060
Mailing Address - Fax:763-428-1711
Practice Address - Street 1:21308 JOHN MILLESS DR
Practice Address - Street 2:SUITE 101B
Practice Address - City:ROGERS
Practice Address - State:MN
Practice Address - Zip Code:55374-4708
Practice Address - Country:US
Practice Address - Phone:763-428-4060
Practice Address - Fax:763-428-1711
Is Sole Proprietor?:No
Enumeration Date:2006-04-19
Last Update Date:2009-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP4169103T00000X, 103G00000X, 103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN719220700Medicaid
MNR92351Medicare UPIN
MN719220700Medicaid