Provider Demographics
NPI:1861233421
Name:EMERALD BRIDGE WELLNESS PLLC
Entity type:Organization
Organization Name:EMERALD BRIDGE WELLNESS PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:AL
Authorized Official - Middle Name:
Authorized Official - Last Name:BERRY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:469-915-4211
Mailing Address - Street 1:14033 COMMERCE AVE NE STE 300
Mailing Address - Street 2:
Mailing Address - City:PRIOR LAKE
Mailing Address - State:MN
Mailing Address - Zip Code:55372-1515
Mailing Address - Country:US
Mailing Address - Phone:512-763-7086
Mailing Address - Fax:
Practice Address - Street 1:14033 COMMERCE AVE NE STE 300
Practice Address - Street 2:
Practice Address - City:PRIOR LAKE
Practice Address - State:MN
Practice Address - Zip Code:55372-1515
Practice Address - Country:US
Practice Address - Phone:512-763-7086
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-06-05
Last Update Date:2025-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty