Healthcare Provider Details

I. General information

NPI: 1326435231
Provider Name (Legal Business Name): DANIEL ALEX ZUSTIAK M.A. LMFT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/17/2015
Last Update Date: 05/14/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1516 W LAKE ST STE 110
MINNEAPOLIS MN
55408
US

IV. Provider business mailing address

2712 FREMONT AVE S
MINNEAPOLIS MN
55408-1122
US

V. Phone/Fax

Practice location:
  • Phone: 612-872-8218
  • Fax: 612-874-8885
Mailing address:
  • Phone: 612-822-1357
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number3014
License Number StateMN
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number3014
License Number StateMN
# 3
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number3014
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: