Healthcare Provider Details

I. General information

NPI: 1104414515
Provider Name (Legal Business Name): BRETT SHAROCKMAN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/03/2021
Last Update Date: 02/06/2026
Certification Date: 02/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11010 PRAIRIE LAKES DR STE 350
EDEN PRAIRIE MN
55344-3801
US

IV. Provider business mailing address

8044 BELAIR LN
EDEN PRAIRIE MN
55347-1103
US

V. Phone/Fax

Practice location:
  • Phone: 952-746-2522
  • Fax:
Mailing address:
  • Phone: 507-400-8635
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number305850
License Number StateMN
# 2
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number4208
License Number StateMN
# 3
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number11496-125
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: