Provider Demographics
NPI:1104936913
Name:WEISBERG, MARK B (PHD, ABPP)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:B
Last Name:WEISBERG
Suffix:
Gender:M
Credentials:PHD, ABPP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:430 OAK GROVE ST
Mailing Address - Street 2:SUITE 407
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55403-3253
Mailing Address - Country:US
Mailing Address - Phone:612-520-9159
Mailing Address - Fax:
Practice Address - Street 1:430 OAK GROVE ST
Practice Address - Street 2:SUITE 407
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55403-3253
Practice Address - Country:US
Practice Address - Phone:612-520-9159
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP 1311103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical