Healthcare Provider Details

I. General information

NPI: 1437844552
Provider Name (Legal Business Name): KEBRA GEBREAB
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/05/2023
Last Update Date: 04/05/2023
Certification Date: 04/03/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5775 WAYZATA BLVD STE 700
ST LOUIS PARK MN
55416-1233
US

IV. Provider business mailing address

5775 WAYZATA BLVD STE 700
ST LOUIS PARK MN
55416-1233
US

V. Phone/Fax

Practice location:
  • Phone: 763-312-1878
  • Fax: 763-316-3123
Mailing address:
  • Phone: 763-312-1878
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: