Healthcare Provider Details

I. General information

NPI: 1558383794
Provider Name (Legal Business Name): BRIAN EDWARD POWERS II PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/24/2006
Last Update Date: 09/05/2024
Certification Date: 09/05/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4500 PARK GLEN RD SUITE 155
ST LOUIS PARK MN
55416-4871
US

IV. Provider business mailing address

4500 PARK GLEN RD SUITE 155
ST LOUIS PARK MN
55416-4871
US

V. Phone/Fax

Practice location:
  • Phone: 612-986-4397
  • Fax: 952-495-1409
Mailing address:
  • Phone: 612-986-4397
  • Fax: 952-495-1409

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number2546
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: