Provider Demographics
NPI:1174939961
Name:VAN WYK, EMILY ROSE (PSYD, LP)
Entity type:Individual
Prefix:DR
First Name:EMILY
Middle Name:ROSE
Last Name:VAN WYK
Suffix:
Gender:F
Credentials:PSYD, LP
Other - Prefix:DR
Other - First Name:EMILY
Other - Middle Name:ROSE
Other - Last Name:BUOEN; COISMAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PSYD, LP
Mailing Address - Street 1:2355 BENJAMIN ST NE
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55418-4001
Mailing Address - Country:US
Mailing Address - Phone:651-485-8417
Mailing Address - Fax:651-925-0427
Practice Address - Street 1:2355 BENJAMIN ST NE
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55418
Practice Address - Country:US
Practice Address - Phone:651-485-8417
Practice Address - Fax:651-925-0427
Is Sole Proprietor?:No
Enumeration Date:2014-07-01
Last Update Date:2020-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP5747103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical