Basic Information
| Provider Information | |||||||||
| NPI: | 1174939961 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | VAN WYK | ||||||||
| FirstName: | EMILY | ||||||||
| MiddleName: | ROSE | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PSY.D., LP | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | BUOEN; COISMAN | ||||||||
| OtherFirstName: | EMILY | ||||||||
| OtherMiddleName: | ROSE | ||||||||
| OtherNamePrefix: | DR. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | PSY.D., LP | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 2355 BENJAMIN ST NE | ||||||||
| Address2: | |||||||||
| City: | MINNEAPOLIS | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554184001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6514858417 | ||||||||
| FaxNumber: | 6519250427 | ||||||||
| Practice Location | |||||||||
| Address1: | 2355 BENJAMIN ST NE | ||||||||
| Address2: | |||||||||
| City: | MINNEAPOLIS | ||||||||
| State: | MN | ||||||||
| PostalCode: | 55418 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6514858417 | ||||||||
| FaxNumber: | 6519250427 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/01/2014 | ||||||||
| LastUpdateDate: | 08/26/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 08/26/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TC0700X | LP5747 | MN | Y | Behavioral Health & Social Service Providers | Psychologist | Clinical |
No ID Information.