Healthcare Provider Details

I. General information

NPI: 1821689894
Provider Name (Legal Business Name): MARISA HUTTERER LICSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/01/2021
Last Update Date: 02/01/2021
Certification Date: 02/01/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2400 W 64TH ST
RICHFIELD MN
55423-1001
US

IV. Provider business mailing address

2400 W 64TH ST
RICHFIELD MN
55423-1001
US

V. Phone/Fax

Practice location:
  • Phone: 612-346-9853
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number27433
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: