NORTHERN WATERS CLINIC PLLC NPI 1316445455

NPI Information

NPI: 1316445455
Provider Name: NORTHERN WATERS CLINIC, PLLC

Other Name: NORTHERN WATERS CLINIC

Classification: Clinic/Center - 261QM0801X
Entity Type: Organization

Specialization: Mental Health (Including Community Mental Health Center)

Address:
4899 MILLER TRUNK HWY STE 208
HERMANTOWN, MN
ZIP 55811
Phone: (218) 391-9860
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NORTHERN WATERS CLINIC, PLLC is a mental health (including community mental health center) clinic center in Hermantown, MN. NORTHERN WATERS CLINIC, PLLC NPI is 1316445455. The provider is registered as an organization entity type and is a multi-specialty group.
The provider Other Name Is Northern Waters Clinic.

The provider's business location address is:

4899 MILLER TRUNK HWY STE 208
HERMANTOWN, MN
ZIP 55811-582
Phone: (218) 391-9860
Fax: (218) 391-9860

The provider's authorized official is Melissa Ann Maki .
The authorized official title is Co-owner and has the following contact phone number (218) 727-3888.

The enumeration date for this NPI number is 1/23/2018 and was last updated on 3/24/2021.

Taxonomy Codes

The NPI record includes the healthcare provider taxonomy classification, state license number and state of licensure. The following information regarding the scope of practice of this provider is available:

No.	Taxonomy Code	Taxonomy Clasification	Taxonomy Specialization	License Number	License State	Primary
1	163WP0807X	Registered Nurse	Psychiatric/Mental Health, Child & Adolescent	2318	MINNESOTA	No
2	163WP0808X	Registered Nurse	Psychiatric/Mental Health	2318	MINNESOTA	No
3	261QM0801X	Clinic/Center	Mental Health (Including Community Mental Health Center)			Yes

Other Identifiers

The following information regarding additional identifiers associated to this NPI record includes the other identifier number, identifier type, identifier state and issuer.

No.	Other Provider Identifier	Other Provider Identifier Type	Other Provider Identifier State	Other Provider Identifier Issuer
1	1295014520	MEDICAID	MINNESOTA

What is NPI?

NPI stands for National Provider Identifier. The NPI is a 10-digit identification number that is completely unique. The NPI number by itself does not contain any identifiable information such as a provider’s speciality or location. The NPI is assigned to individuals or organizacions for their lifespan and it is independent of key provider information type updates like a change of practices, location or speciality.

This page was last updated on: 5/5/2024

NPI Synchronization or Removal

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