Healthcare Provider Details

I. General information

NPI: 1619134574
Provider Name (Legal Business Name): MARK HUTTEMIER LPP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/19/2008
Last Update Date: 05/19/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3915 GOLDEN VALLEY ROAD COURAGE CENTER
GOLDEN VALLEY MN
55422
US

IV. Provider business mailing address

3915 GOLDEN VALLEY ROAD COURAGE CENTER
GOLDEN VALLEY MN
55422
US

V. Phone/Fax

Practice location:
  • Phone: 763-520-0516
  • Fax:
Mailing address:
  • Phone: 763-520-0516
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License NumberLPP 0117
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: