Provider Demographics
NPI:1306115969
Name:BRUNSGAARD, JUDY KAY (LICSW)
Entity type:Individual
Prefix:
First Name:JUDY
Middle Name:KAY
Last Name:BRUNSGAARD
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7236 FORESTVIEW LN N
Mailing Address - Street 2:
Mailing Address - City:MAPLE GROVE
Mailing Address - State:MN
Mailing Address - Zip Code:55369-5656
Mailing Address - Country:US
Mailing Address - Phone:763-416-4167
Mailing Address - Fax:763-416-4137
Practice Address - Street 1:7236 FORESTVIEW LN N
Practice Address - Street 2:
Practice Address - City:MAPLE GROVE
Practice Address - State:MN
Practice Address - Zip Code:55369-5656
Practice Address - Country:US
Practice Address - Phone:763-416-4167
Practice Address - Fax:763-416-4137
Is Sole Proprietor?:No
Enumeration Date:2011-12-27
Last Update Date:2015-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI7902-1231041C0700X
MN192091041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN1306115969Medicaid
MN1306115969Medicaid