MEDICARE: JUSTIN MICHAEL MEDNICK

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
1	101YM0800X	Mental Health Counselor

General Provider Information

NPI Number	:	1639615800
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JUSTIN MICHAEL MEDNICK

Provider Business Mailing Address
First Line	:	7600 PARKLAWN AVE
Second Line	:	380
City	:	EDINA
State	:	MN
Zip	:	55435-5125
Country	:	US
Telephone Number	:	612-203-2961
Fax Number	:	952-831-0033

Provider Business Practice Location Address
First Line	:	101 5TH ST E
Second Line	:	208
City	:	NORTHFIELD
State	:	MN
Zip	:	55057-2067
Country	:	US
Telephone Number	:	507-222-9230
Fax Number	:	507-786-9877

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/12/2017
Last Update Date	:	01/12/2017

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Directions to “ JUSTIN MICHAEL MEDNICK ” Practice Location

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