Provider Demographics
NPI:1831295278
Name:DENNIS M. BREKKE, LTD.
Entity type:Organization
Organization Name:DENNIS M. BREKKE, LTD.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DENNIS
Authorized Official - Middle Name:M
Authorized Official - Last Name:BREKKE
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:612-991-1769
Mailing Address - Street 1:10331 108TH PL N
Mailing Address - Street 2:
Mailing Address - City:MAPLE GROVE
Mailing Address - State:MN
Mailing Address - Zip Code:55369-2638
Mailing Address - Country:US
Mailing Address - Phone:612-991-1769
Mailing Address - Fax:
Practice Address - Street 1:2021 E HENNEPIN AVE
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55413-1896
Practice Address - Country:US
Practice Address - Phone:612-991-1769
Practice Address - Fax:612-395-5585
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-15
Last Update Date:2012-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN546347500Medicaid
MN01992BROtherBCBS PROVIDER NUMBER
MN1H217BROtherBCBS PROVIDER NUMBER