Healthcare Provider Details

I. General information

NPI: 1033025077
Provider Name (Legal Business Name): MARK HANTLA LPCC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/20/2026
Last Update Date: 08/20/2026
Certification Date: 08/20/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

771 RAYMOND AVE
SAINT PAUL MN
55114-1522
US

IV. Provider business mailing address

4624 BLOOMINGTON AVE
MINNEAPOLIS MN
55407-3663
US

V. Phone/Fax

Practice location:
  • Phone: 651-243-2292
  • Fax:
Mailing address:
  • Phone: 712-899-7416
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number5800
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: