Provider Demographics
NPI:1376165795
Name:BARTLEY, MARK (MA, LPC)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:BARTLEY
Suffix:
Gender:M
Credentials:MA, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:904 MAINSTREET STE 200
Mailing Address - Street 2:
Mailing Address - City:HOPKINS
Mailing Address - State:MN
Mailing Address - Zip Code:55343-7589
Mailing Address - Country:US
Mailing Address - Phone:952-562-4116
Mailing Address - Fax:
Practice Address - Street 1:904 MAINSTREET STE 200
Practice Address - Street 2:
Practice Address - City:HOPKINS
Practice Address - State:MN
Practice Address - Zip Code:55343-7589
Practice Address - Country:US
Practice Address - Phone:866-522-2472
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-05-07
Last Update Date:2020-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2396101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
1989OtherCOMMERCIAL IN PROCESS