Healthcare Provider Details

I. General information

NPI: 1215692785
Provider Name (Legal Business Name): MOMENTA MENTAL HEALTH
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/01/2021
Last Update Date: 01/13/2022
Certification Date: 01/13/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2179 4TH ST STE 2F
WHITE BEAR LAKE MN
55110-3041
US

IV. Provider business mailing address

1060 HILLVALE AVE N
OAKDALE MN
55128-5859
US

V. Phone/Fax

Practice location:
  • Phone: 701-426-8833
  • Fax:
Mailing address:
  • Phone: 651-381-6611
  • 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 Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. BRIANNE M MARION
Title or Position: OWNER
Credential: PSYD
Phone: 651-381-6611