Provider Demographics
NPI:1669992186
Name:BRUSS, STEPHANIE (PSYD)
Entity type:Individual
Prefix:DR
First Name:STEPHANIE
Middle Name:
Last Name:BRUSS
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:821 RAYMOND AVE # 130C
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55114-1503
Mailing Address - Country:US
Mailing Address - Phone:612-440-6545
Mailing Address - Fax:
Practice Address - Street 1:821 RAYMOND AVE # 130C
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55114-1503
Practice Address - Country:US
Practice Address - Phone:612-440-6545
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-06-26
Last Update Date:2018-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP5821103TC0700X, 103TF0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TF0200XBehavioral Health & Social Service ProvidersPsychologistForensic
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty