Healthcare Provider Details

I. General information

NPI: 1679067912
Provider Name (Legal Business Name): LAURA KAY ENNIS LMFT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: LAURA BETTELYOUN LMFT

II. Dates (important events)

Enumeration Date: 06/20/2018
Last Update Date: 11/07/2025
Certification Date: 11/07/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14500 99TH AVE N
MAPLE GROVE MN
55369-4730
US

IV. Provider business mailing address

14500 99TH AVE N
MAPLE GROVE MN
55369-4730
US

V. Phone/Fax

Practice location:
  • Phone: 763-898-1000
  • Fax:
Mailing address:
  • Phone: 763-898-1000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number3461
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: