Healthcare Provider Details

I. General information

NPI: 1689449894
Provider Name (Legal Business Name): MARISA VAPE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/17/2023
Last Update Date: 11/17/2023
Certification Date: 11/17/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

631 BUCHANAN ST NE
MINNEAPOLIS MN
55413-2519
US

IV. Provider business mailing address

631 BUCHANAN ST NE
MINNEAPOLIS MN
55413-2519
US

V. Phone/Fax

Practice location:
  • Phone: 612-251-7288
  • Fax:
Mailing address:
  • Phone: 612-251-7288
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: