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General NPI Number Information
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NPI Number | 1316445455
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Entity Type | Organization
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Legal Business Name | NORTHERN WATERS CLINIC
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Dates
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Enumeration Date | 01/23/2018
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Last Update Date | 12/04/2025
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Provider Practice Location Address
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Address Line | 4899 MILLER TRUNK HWY STE 208
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City | HERMANTOWN
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State | MN
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Zip | 55811-1582
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Country | US
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Telephone | 218-391-9860
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Fax | 218-391-9860
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Provider Business Mailing Address
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Address Line | 1702 MILLER TRUNK HWY STE 214
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City | DULUTH
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State | MN
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Zip | 55811-4448
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | CO-OWNER
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Name | DR. MELISSA ANN MAKI
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Credential | NP
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Telephone | 218-727-3888
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 163WP0808X
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Taxonomy Name | Psychiatric/Mental Health Registered Nurse
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License Number | 2318
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License Number State | MN
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Taxonomy #2
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Taxonomy Code | 163WP0807X
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Taxonomy Name | Child & Adolescent Psychiatric/Mental Health Registered Nurse
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License Number | 2318
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License Number State | MN
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Taxonomy #3
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Taxonomy Code | 261QM0801X
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Taxonomy Name | Mental Health Clinic/Center (Including Community Mental Health Center)
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License Number |
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License Number State |
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