Provider Demographics
NPI:1124374152
Name:BARTUSCH, MOLLY MARIE (MA)
Entity Type:Individual
Prefix:
First Name:MOLLY
Middle Name:MARIE
Last Name:BARTUSCH
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:525 PORTLAND AVE SOUTH
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55415-1569
Mailing Address - Country:US
Mailing Address - Phone:612-596-7898
Mailing Address - Fax:612-677-6357
Practice Address - Street 1:525 PORTLAND AVE SOUTH
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55415-1569
Practice Address - Country:US
Practice Address - Phone:612-596-7898
Practice Address - Fax:612-677-6357
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-27
Last Update Date:2015-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA000356106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist