Provider Demographics
NPI:1699883363
Name:BROSSART, ELIZABETH A (MED)
Entity type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:A
Last Name:BROSSART
Suffix:
Gender:F
Credentials:MED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1463 I94 BUSINESS LOOP E
Mailing Address - Street 2:
Mailing Address - City:DICKINSON
Mailing Address - State:ND
Mailing Address - Zip Code:58601-6434
Mailing Address - Country:US
Mailing Address - Phone:701-227-7500
Mailing Address - Fax:
Practice Address - Street 1:1463 I94 BUSINESS LOOP E
Practice Address - Street 2:
Practice Address - City:DICKINSON
Practice Address - State:ND
Practice Address - Zip Code:58601-6434
Practice Address - Country:US
Practice Address - Phone:701-227-7500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-25
Last Update Date:2022-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171M00000X, 101Y00000X
ND560-9-1-06-186101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
No101Y00000XBehavioral Health & Social Service ProvidersCounselor