Provider Demographics
NPI:1417528043
Name:MISSION WELLNESS MN PLLC
Entity Type:Organization
Organization Name:MISSION WELLNESS MN PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/CEO
Authorized Official - Prefix:
Authorized Official - First Name:MICHELLE
Authorized Official - Middle Name:
Authorized Official - Last Name:MURPHY
Authorized Official - Suffix:
Authorized Official - Credentials:CNP
Authorized Official - Phone:612-271-6807
Mailing Address - Street 1:3315 MONDAMIN ST
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55417-2056
Mailing Address - Country:US
Mailing Address - Phone:612-703-6539
Mailing Address - Fax:844-703-6539
Practice Address - Street 1:6636 CEDAR AVE S STE 380
Practice Address - Street 2:
Practice Address - City:RICHFIELD
Practice Address - State:MN
Practice Address - Zip Code:55423-2712
Practice Address - Country:US
Practice Address - Phone:612-271-6807
Practice Address - Fax:844-703-6539
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-07-06
Last Update Date:2021-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN1972580058Medicaid