Provider Demographics
NPI:1770063638
Name:THOMPSON, BRENNA LYNN (LCSW)
Entity type:Individual
Prefix:
First Name:BRENNA
Middle Name:LYNN
Last Name:THOMPSON
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:BRENNA
Other - Middle Name:LYNN
Other - Last Name:MODIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1816 7TH ST NW
Mailing Address - Street 2:
Mailing Address - City:MINOT
Mailing Address - State:ND
Mailing Address - Zip Code:58703-1315
Mailing Address - Country:US
Mailing Address - Phone:701-720-7327
Mailing Address - Fax:
Practice Address - Street 1:600 22ND AVE NW STE 2
Practice Address - Street 2:
Practice Address - City:MINOT
Practice Address - State:ND
Practice Address - Zip Code:58703-0986
Practice Address - Country:US
Practice Address - Phone:701-818-7727
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-20
Last Update Date:2018-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND4176101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health