Individual
BRENDA LYNN DESTACHE
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Credential
MSLP
Contact information
Practice address
1976 WOODALE DR, WOODBURY, MN 55125
(651) 730-8464
Mailing address
391 JESSE JAMES LN, MAHTOMEDI, MN 55115-1794
(651) 730-8464
Taxonomy
Speciality
Code
Description
License number
State
103T00000X
Psychologist
Primary
LP2836
MN
Other
Enumeration date
04/29/2008
Last updated
04/29/2008
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