Healthcare Provider Details

I. General information

NPI: 1700902889
Provider Name (Legal Business Name): ANTOINETTE MARIA MOTTL M.A.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/21/2007
Last Update Date: 08/20/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

800 E 28TH ST
MINNEAPOLIS MN
55407-3723
US

IV. Provider business mailing address

1317 BIRCHVIEW DR
MAPLEWOOD MN
55119-3164
US

V. Phone/Fax

Practice location:
  • Phone: 612-863-8633
  • Fax: 612-863-8516
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: