Provider Demographics
NPI:1487843355
Name:MLADNICK, PAUL LUKE (LMFT)
Entity Type:Individual
Prefix:MR
First Name:PAUL
Middle Name:LUKE
Last Name:MLADNICK
Suffix:
Gender:M
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1068 SO LAKE ST
Mailing Address - Street 2:SUITE 109
Mailing Address - City:FOREST LAKE
Mailing Address - State:MN
Mailing Address - Zip Code:55025
Mailing Address - Country:US
Mailing Address - Phone:612-719-7966
Mailing Address - Fax:
Practice Address - Street 1:1068 SO LAKE ST
Practice Address - Street 2:#109
Practice Address - City:FOREST LAKE
Practice Address - State:MN
Practice Address - Zip Code:55025
Practice Address - Country:US
Practice Address - Phone:612-719-7966
Practice Address - Fax:651-982-6035
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-17
Last Update Date:2007-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1306106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist