Provider Demographics
NPI:1073870721
Name:REINHOLTZ, MARK (LADC)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:REINHOLTZ
Suffix:
Gender:M
Credentials:LADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:297 CENTURY AVE S
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55119-5206
Mailing Address - Country:US
Mailing Address - Phone:651-266-1497
Mailing Address - Fax:651-266-1411
Practice Address - Street 1:297 CENTURY AVE S
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55119-5206
Practice Address - Country:US
Practice Address - Phone:651-266-1497
Practice Address - Fax:651-266-1411
Is Sole Proprietor?:Yes
Enumeration Date:2012-04-19
Last Update Date:2012-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN302190101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)