Healthcare Provider Details

I. General information

NPI: 1316445455
Provider Name (Legal Business Name): NORTHERN WATERS CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/23/2018
Last Update Date: 12/04/2025
Certification Date: 12/04/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4899 MILLER TRUNK HWY STE 208
HERMANTOWN MN
55811-1582
US

IV. Provider business mailing address

1702 MILLER TRUNK HWY STE 214
DULUTH MN
55811-4448
US

V. Phone/Fax

Practice location:
  • Phone: 218-391-9860
  • Fax: 218-391-9860
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code163WP0807X
TaxonomyChild & Adolescent Psychiatric/Mental Health Registered Nurse
License Number2318
License Number StateMN
# 3
Primary TaxonomyN
Taxonomy Code163WP0808X
TaxonomyPsychiatric/Mental Health Registered Nurse
License Number2318
License Number StateMN

VIII. Authorized Official

Name: DR. MELISSA ANN MAKI
Title or Position: CO-OWNER
Credential: NP
Phone: 218-727-3888