Provider Demographics
NPI:1952939431
Name:BARTLETT, BRIAN (MS)
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:
Last Name:BARTLETT
Suffix:
Gender:M
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11102 3RD ST N
Mailing Address - Street 2:
Mailing Address - City:LAKE ELMO
Mailing Address - State:MN
Mailing Address - Zip Code:55042-1503
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:405 STAGELINE RD
Practice Address - Street 2:
Practice Address - City:HUDSON
Practice Address - State:WI
Practice Address - Zip Code:54016-7848
Practice Address - Country:US
Practice Address - Phone:715-531-6755
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-03-30
Last Update Date:2020-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI7592-125101YP2500X
WI15836-131101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional