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NPI Code Detail

MEDICARE: ELIZA WOODWARD HARTLEY

MEDICARE: ELIZA WOODWARD HARTLEY
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1101YM0800XMental Health Counselor
2101Y00000XCounselor

General Provider Information

NPI Number : 1215671557
Entity Type Code : Individual
Provider Name (Legal Business Name) : ELIZA WOODWARD HARTLEY
Provider Business Mailing Address
First Line : 5 SPARROW LN
Second Line :
City : NORTH OAKS
State : MN
Zip : 55127-6453
Country : US
Telephone Number : 651-492-4770
Fax Number :
Provider Business Practice Location Address
First Line : 1155 NORTHLAND DR
Second Line :
City : MENDOTA HEIGHTS
State : MN
Zip : 55120-1288
Country : US
Telephone Number : 612-223-8898
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 04/22/2022
Last Update Date : 04/20/2023

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