Healthcare Provider Details

I. General information

NPI: 1730879768
Provider Name (Legal Business Name): MEARA VON MALOTTKE HILLMAN MT-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/12/2023
Last Update Date: 06/14/2023
Certification Date: 06/14/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1504 SAINT CLAIR AVE APT 108
SAINT PAUL MN
55105-2351
US

IV. Provider business mailing address

315 E 5TH ST STE 202
WATERLOO IA
50703-4757
US

V. Phone/Fax

Practice location:
  • Phone: 314-566-0206
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225A00000X
TaxonomyMusic Therapist
License Number16811
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: