Provider Demographics
NPI:1235779315
Name:HURTADO MINO, MARTHA (LICSW)
Entity Type:Individual
Prefix:
First Name:MARTHA
Middle Name:
Last Name:HURTADO MINO
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:712 N FRONT ST
Mailing Address - Street 2:
Mailing Address - City:CROOKSTON
Mailing Address - State:MN
Mailing Address - Zip Code:56716-1252
Mailing Address - Country:US
Mailing Address - Phone:218-277-9905
Mailing Address - Fax:
Practice Address - Street 1:712 N FRONT ST
Practice Address - Street 2:
Practice Address - City:CROOKSTON
Practice Address - State:MN
Practice Address - Zip Code:56716-1252
Practice Address - Country:US
Practice Address - Phone:954-668-3621
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-07
Last Update Date:2022-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN16103101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health