Provider Demographics
NPI:1588021190
Name:WACKER, EMILY
Entity Type:Individual
Prefix:
First Name:EMILY
Middle Name:
Last Name:WACKER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3351 XYLON AVE S
Mailing Address - Street 2:
Mailing Address - City:ST LOUIS PARK
Mailing Address - State:MN
Mailing Address - Zip Code:55426-3807
Mailing Address - Country:US
Mailing Address - Phone:715-377-5192
Mailing Address - Fax:
Practice Address - Street 1:2550 UNIVERSITY AVE W
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55114-1052
Practice Address - Country:US
Practice Address - Phone:952-993-6200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-01-27
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2991106H00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program