Basic Information
Provider Information | |||||||||
NPI: | 1548296502 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | BRANDENBURG | ||||||||
FirstName: | DANA | ||||||||
MiddleName: |   | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | PSYD, LP | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 2020 E 28TH ST | ||||||||
Address2: | UFP SMILEY'S CLINIC | ||||||||
City: | MINNEAPOLIS | ||||||||
State: | MN | ||||||||
PostalCode: | 554071394 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6123330770 | ||||||||
FaxNumber: | 6123331986 | ||||||||
Practice Location | |||||||||
Address1: | 2020 E 28TH ST | ||||||||
Address2: | UFP SMILEY'S CLINIC | ||||||||
City: | MINNEAPOLIS | ||||||||
State: | MN | ||||||||
PostalCode: | 554071394 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6123330770 | ||||||||
FaxNumber: | 6123331986 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/23/2006 | ||||||||
LastUpdateDate: | 07/14/2010 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TC0700X | LP 4535 | MN | Y |   | Behavioral Health & Social Service Providers | Psychologist | Clinical |
ID Information
ID | Type | State | Issuer | Description | 615T1BR | 01 | MN | BCBS SMILEY'S | OTHER | 61-53755 | 01 | MN | UBH | OTHER | A049 | 01 | MN | CHAMPUS | OTHER | 1042740 | 01 | MN | PREFERRED ONE | OTHER | 175R2BR | 01 | MN | BCBS | OTHER | HP48442 | 01 | MN | HEALTHPARTNERS | OTHER | 577460800 | 05 | MN |   | MEDICAID | 113221 | 01 | MN | UCARE | OTHER | 2280059 | 01 | MN | ARAZ | OTHER |