MEDICARE: DANIEL CHARLES REBEK PHD, LP

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	103TC0700X	Clinical Psychologist	5755	MN

General Provider Information

NPI Number	:	1245712439
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DANIEL CHARLES REBEK PHD, LP

Provider Business Mailing Address
First Line	:	2497 7TH AVE E STE 101
Second Line	:
City	:	NORTH SAINT PAUL
State	:	MN
Zip	:	55109-2946
Country	:	US
Telephone Number	:	651-769-6437
Fax Number	:	651-769-6449

Provider Business Practice Location Address
First Line	:	3460 WASHINGTON DR STE 200
Second Line	:
City	:	EAGAN
State	:	MN
Zip	:	55122-4302
Country	:	US
Telephone Number	:	651-769-6200
Fax Number	:	651-769-6249

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

Provider Enumeration Date	:	09/04/2018
Last Update Date	:	09/04/2018

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