Provider Demographics
NPI:1427658749
Name:BRENKE, TERESA L
Entity type:Individual
Prefix:MRS
First Name:TERESA
Middle Name:L
Last Name:BRENKE
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 1:436 5TH AVE E
Mailing Address - Street 2:
Mailing Address - City:SHAKOPEE
Mailing Address - State:MN
Mailing Address - Zip Code:55379-1534
Mailing Address - Country:US
Mailing Address - Phone:612-802-2987
Mailing Address - Fax:
Practice Address - Street 1:436 5TH AVE E
Practice Address - Street 2:
Practice Address - City:SHAKOPEE
Practice Address - State:MN
Practice Address - Zip Code:55379-1534
Practice Address - Country:US
Practice Address - Phone:612-802-2987
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-27
Last Update Date:2021-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
103K00000X
MNA-3274491
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
No103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst