Healthcare Provider Details

I. General information

NPI: 1245712439
Provider Name (Legal Business Name): DANIEL CHARLES REBEK PHD, LP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/04/2018
Last Update Date: 09/04/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3460 WASHINGTON DR STE 200
EAGAN MN
55122-4302
US

IV. Provider business mailing address

2497 7TH AVE E STE 101
NORTH SAINT PAUL MN
55109-2946
US

V. Phone/Fax

Practice location:
  • Phone: 651-769-6200
  • Fax: 651-769-6249
Mailing address:
  • Phone: 651-769-6437
  • Fax: 651-769-6449

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number5755
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: