Healthcare Provider Details

I. General information

NPI: 1235779315
Provider Name (Legal Business Name): MARTHA HURTADO MINO LICSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/07/2020
Last Update Date: 03/08/2022
Certification Date: 03/08/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

712 N FRONT ST
CROOKSTON MN
56716-1252
US

IV. Provider business mailing address

712 N FRONT ST
CROOKSTON MN
56716-1252
US

V. Phone/Fax

Practice location:
  • Phone: 954-668-3621
  • Fax:
Mailing address:
  • Phone: 218-277-9905
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number16103
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: