Provider Demographics
NPI:1902432248
Name:WAKEFIELD, BROOKE TAYLOR
Entity Type:Individual
Prefix:MS
First Name:BROOKE
Middle Name:TAYLOR
Last Name:WAKEFIELD
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8421 WAYZATA BLVD STE 250
Mailing Address - Street 2:
Mailing Address - City:GOLDEN VALLEY
Mailing Address - State:MN
Mailing Address - Zip Code:55426-1382
Mailing Address - Country:US
Mailing Address - Phone:952-835-6540
Mailing Address - Fax:952-835-6650
Practice Address - Street 1:8421 WAYZATA BLVD STE 250
Practice Address - Street 2:
Practice Address - City:GOLDEN VALLEY
Practice Address - State:MN
Practice Address - Zip Code:55426-1382
Practice Address - Country:US
Practice Address - Phone:952-835-6540
Practice Address - Fax:952-835-6650
Is Sole Proprietor?:No
Enumeration Date:2020-03-18
Last Update Date:2020-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN1336460518Other02 - ORGANIZATION