Provider Demographics
NPI:1821961681
Name:NEGUSSIE, ERMIAS D
Entity type:Individual
Prefix:
First Name:ERMIAS
Middle Name:D
Last Name:NEGUSSIE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5221 VIKING DR STE 300
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:MN
Mailing Address - Zip Code:55435-5323
Mailing Address - Country:US
Mailing Address - Phone:651-502-2945
Mailing Address - Fax:612-230-5364
Practice Address - Street 1:5221 VIKING DR STE 300
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:MN
Practice Address - Zip Code:55435-5323
Practice Address - Country:US
Practice Address - Phone:651-502-2945
Practice Address - Fax:612-230-5364
Is Sole Proprietor?:No
Enumeration Date:2025-09-27
Last Update Date:2025-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician