Provider Demographics
NPI:1558383794
Name:POWERS, BRIAN EDWARD II (PHD)
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:EDWARD
Last Name:POWERS
Suffix:II
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4500 PARK GLEN RD
Mailing Address - Street 2:SUITE 155
Mailing Address - City:ST LOUIS PARK
Mailing Address - State:MN
Mailing Address - Zip Code:55416-4871
Mailing Address - Country:US
Mailing Address - Phone:612-986-4397
Mailing Address - Fax:952-495-1409
Practice Address - Street 1:4500 PARK GLEN RD
Practice Address - Street 2:SUITE 155
Practice Address - City:ST LOUIS PARK
Practice Address - State:MN
Practice Address - Zip Code:55416-4871
Practice Address - Country:US
Practice Address - Phone:612-986-4397
Practice Address - Fax:952-495-1409
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP 2546103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN5H617POOtherBLUE CROSS ID
MN61-42917OtherUBH ID