Healthcare Provider Details

I. General information

NPI: 1457680266
Provider Name (Legal Business Name): VAN MARK GEMMELL PSYD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/08/2009
Last Update Date: 06/23/2026
Certification Date: 06/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7101 YORK AVE S STE 365
EDINA MN
55435-7500
US

IV. Provider business mailing address

1068 LAKE ST S STE 109
FOREST LAKE MN
55025-2633
US

V. Phone/Fax

Practice location:
  • Phone: 612-703-4293
  • Fax: 612-314-8212
Mailing address:
  • Phone: 651-982-4792
  • Fax: 612-314-8212

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberLP5177
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: