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General NPI Number Information
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NPI Number | 1861233421
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Entity Type | Organization
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Legal Business Name | EMERALD BRIDGE WELLNESS PLLC
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Dates
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Enumeration Date | 06/05/2024
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Last Update Date | 03/02/2025
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Provider Practice Location Address
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Address Line | 14033 COMMERCE AVE NE STE 300
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City | PRIOR LAKE
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State | MN
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Zip | 55372-1515
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Country | US
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Telephone | 512-763-7086
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Fax |
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Provider Business Mailing Address
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Address Line | 14033 COMMERCE AVE NE STE 300
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City | PRIOR LAKE
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State | MN
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Zip | 55372-1515
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Country | US
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Telephone | 512-763-7086
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Fax |
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Authorized Official
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Title or Position | MANAGER
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Name | AL BERRY
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Credential |
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Telephone | 469-915-4211
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363LP0808X
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Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
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License Number |
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License Number State |
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