MEDICARE: BRIAN EDWARD POWERS II PHD

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	2546	MN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	5H617PO	OTHER	MN	BLUE CROSS ID
2	61-42917	OTHER	MN	UBH ID

General Provider Information

NPI Number	:	1558383794
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BRIAN EDWARD POWERS II PHD

Provider Business Mailing Address
First Line	:	4500 PARK GLEN RD
Second Line	:	SUITE 155
City	:	ST LOUIS PARK
State	:	MN
Zip	:	55416-4871
Country	:	US
Telephone Number	:	612-986-4397
Fax Number	:	952-495-1409

Provider Business Practice Location Address
First Line	:	4500 PARK GLEN RD
Second Line	:	SUITE 155
City	:	ST LOUIS PARK
State	:	MN
Zip	:	55416-4871
Country	:	US
Telephone Number	:	612-986-4397
Fax Number	:	952-495-1409

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

Provider Enumeration Date	:	07/24/2006
Last Update Date	:	09/05/2024

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Directions to “ BRIAN EDWARD POWERS II PHD” Practice Location

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