Provider Demographics
NPI:1053585083
Name:BRANDT LOER, AUDREY ELISSA (MA, LP)
Entity type:Individual
Prefix:
First Name:AUDREY
Middle Name:ELISSA
Last Name:BRANDT LOER
Suffix:
Gender:F
Credentials:MA, LP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16 9TH ST SE
Mailing Address - Street 2:
Mailing Address - City:LONG PRAIRIE
Mailing Address - State:MN
Mailing Address - Zip Code:56347-1429
Mailing Address - Country:US
Mailing Address - Phone:320-732-6602
Mailing Address - Fax:320-732-6581
Practice Address - Street 1:16 9TH ST SE
Practice Address - Street 2:
Practice Address - City:LONG PRAIRIE
Practice Address - State:MN
Practice Address - Zip Code:56347-1429
Practice Address - Country:US
Practice Address - Phone:320-732-6602
Practice Address - Fax:320-732-6581
Is Sole Proprietor?:No
Enumeration Date:2008-04-22
Last Update Date:2008-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP 4917103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical