Healthcare Provider Details

I. General information

NPI: 1508635368
Provider Name (Legal Business Name): VISCERALIZATIONS PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/21/2023
Last Update Date: 06/17/2024
Certification Date: 06/17/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7400 METRO BLVD STE 211
EDINA MN
55439-2321
US

IV. Provider business mailing address

7400 METRO BLVD STE 211
EDINA MN
55439-2321
US

V. Phone/Fax

Practice location:
  • Phone: 612-940-2136
  • Fax:
Mailing address:
  • Phone: 612-940-2136
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State

VIII. Authorized Official

Name: JACOB SCHUCHMAN FALK
Title or Position: OWNER, CHIEF MANAGER
Credential: LICSW
Phone: 612-940-2136