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:2024-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2546103TC0700X, 103TC0700X
133V00000X
MN2463506363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Multi-Specialty
No133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Multi-Specialty
No363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN5H617POOtherBLUE CROSS ID
MN61-42917OtherUBH ID