Healthcare Provider Details

I. General information

NPI: 1124835210
Provider Name (Legal Business Name): BRIAN DAVID EMMECK
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/12/2024
Last Update Date: 12/13/2024
Certification Date: 12/13/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 SHELARD PKWY STE 520
SAINT LOUIS PARK MN
55426-4932
US

IV. Provider business mailing address

5329 48TH AVE S UNIT 405
MINNEAPOLIS MN
55417-3706
US

V. Phone/Fax

Practice location:
  • Phone: 763-226-5330
  • Fax:
Mailing address:
  • Phone: 763-226-5330
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TS0200X
TaxonomySchool Psychologist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: