Healthcare Provider Details

I. General information

NPI: 1588179410
Provider Name (Legal Business Name): KERRY RYAN BROCKBERG PH.D., LP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/14/2017
Last Update Date: 05/18/2021
Certification Date: 05/18/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11850 BLACKFOOT ST NW STE 405
MINNEAPOLIS MN
55433-2773
US

IV. Provider business mailing address

2925 CHICAGO AVE
MINNEAPOLIS MN
55407-1321
US

V. Phone/Fax

Practice location:
  • Phone: 763-236-0888
  • Fax:
Mailing address:
  • Phone: 612-262-5000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License NumberLP6410
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: