Provider Demographics
NPI:1619553559
Name:BRUA, NICHOLE MARIE
Entity type:Individual
Prefix:
First Name:NICHOLE
Middle Name:MARIE
Last Name:BRUA
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3007 HARBOR LN N STE 1600
Mailing Address - Street 2:
Mailing Address - City:PLYMOUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55447-5142
Mailing Address - Country:US
Mailing Address - Phone:844-395-4119
Mailing Address - Fax:
Practice Address - Street 1:3007 HARBOR LN N STE 1600
Practice Address - Street 2:
Practice Address - City:PLYMOUTH
Practice Address - State:MN
Practice Address - Zip Code:55447-5142
Practice Address - Country:US
Practice Address - Phone:844-395-4119
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-03-22
Last Update Date:2025-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106S00000X
MN306840101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician