Healthcare Provider Details

I. General information

NPI: 1356059687
Provider Name (Legal Business Name): MN MENTAL HEALTH SPECIALISTS PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/07/2022
Last Update Date: 09/13/2023
Certification Date: 09/13/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

303 CREDIT UNION DR STE 12A
ISANTI MN
55040-4010
US

IV. Provider business mailing address

6971 330TH LN NW
PRINCETON MN
55371-4930
US

V. Phone/Fax

Practice location:
  • Phone: 612-296-8901
  • Fax:
Mailing address:
  • Phone: 612-296-8901
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number State

VIII. Authorized Official

Name: MELISSA LYNN MARTINI-TISCHER
Title or Position: MENTAL HEALTH PROFESSIONAL
Credential: MA LPCC
Phone: 612-296-8901