Basic Information
| Provider Information | |||||||||
| NPI: | 1124619713 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BLACK | ||||||||
| FirstName: | BRETT | ||||||||
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| Credential: | PT, DPT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7581 9TH ST N STE 100 | ||||||||
| Address2: | |||||||||
| City: | OAKDALE | ||||||||
| State: | MN | ||||||||
| PostalCode: | 551286635 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6517484338 | ||||||||
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| Practice Location | |||||||||
| Address1: | 945 BROADWAY ST NE STE 165 | ||||||||
| Address2: | |||||||||
| City: | MINNEAPOLIS | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554132769 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6127679917 | ||||||||
| FaxNumber: | 6127679918 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/27/2021 | ||||||||
| LastUpdateDate: | 08/25/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/25/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 11968 | MN | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.