Provider Demographics
NPI:1083208243
Name:SEPULVEDA, MARTHA
Entity Type:Individual
Prefix:
First Name:MARTHA
Middle Name:
Last Name:SEPULVEDA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1421 OAKLAND RD
Mailing Address - Street 2:
Mailing Address - City:WAYZATA
Mailing Address - State:MN
Mailing Address - Zip Code:55391-2247
Mailing Address - Country:US
Mailing Address - Phone:612-616-3736
Mailing Address - Fax:
Practice Address - Street 1:13603 80TH CIR N
Practice Address - Street 2:
Practice Address - City:MAPLE GROVE
Practice Address - State:MN
Practice Address - Zip Code:55369-8961
Practice Address - Country:US
Practice Address - Phone:763-284-3706
Practice Address - Fax:763-274-3121
Is Sole Proprietor?:No
Enumeration Date:2021-02-26
Last Update Date:2021-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health