Healthcare Provider Details

I. General information

NPI: 1740724483
Provider Name (Legal Business Name): MANDI SHIMEK
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/15/2016
Last Update Date: 03/13/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

28 NW 4TH ST STE A
GRAND RAPIDS MN
55744-2714
US

IV. Provider business mailing address

28 NW 4TH ST STE A
GRAND RAPIDS MN
55744-2714
US

V. Phone/Fax

Practice location:
  • Phone: 218-999-7750
  • Fax: 218-999-9461
Mailing address:
  • Phone: 218-999-7750
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberCC01401
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: