Provider Demographics
NPI:1144307471
Name:DEMOTTE, BRENDA JEAN (MSW, LICSW)
Entity type:Individual
Prefix:
First Name:BRENDA
Middle Name:JEAN
Last Name:DEMOTTE
Suffix:
Gender:F
Credentials:MSW, LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13027 GARVIN BROOK LN
Mailing Address - Street 2:
Mailing Address - City:APPLE VALLEY
Mailing Address - State:MN
Mailing Address - Zip Code:55124-7245
Mailing Address - Country:US
Mailing Address - Phone:952-432-2669
Mailing Address - Fax:952-891-1800
Practice Address - Street 1:14985 GLAZIER AVE
Practice Address - Street 2:SUITE 555
Practice Address - City:APPLE VALLEY
Practice Address - State:MN
Practice Address - Zip Code:55124-7484
Practice Address - Country:US
Practice Address - Phone:952-891-2525
Practice Address - Fax:952-891-1800
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN05559101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN990991046670OtherPREFERREDONE ADMINISTRATA
MN02S54DEOtherBLUECROSS AND BLUESHIELD
MN62-41666OtherMEDICA
MNV41193711663852OtherHELATHPARTNERS