MEDICARE: BRETT BLACK PT, DPT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225100000X	Physical Therapist	11968	MN

General Provider Information

NPI Number	:	1124619713
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BRETT BLACK PT, DPT

Provider Business Mailing Address
First Line	:	7581 9TH ST N STE 100
Second Line	:
City	:	OAKDALE
State	:	MN
Zip	:	55128-6635
Country	:	US
Telephone Number	:	651-748-4338
Fax Number	:

Provider Business Practice Location Address
First Line	:	945 BROADWAY ST NE STE 165
Second Line	:
City	:	MINNEAPOLIS
State	:	MN
Zip	:	55413-2769
Country	:	US
Telephone Number	:	612-767-9917
Fax Number	:	612-767-9918

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/27/2021
Last Update Date	:	08/25/2021

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