Provider Demographics
NPI:1619134574
Name:HUTTEMIER, MARK (LPP)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:HUTTEMIER
Suffix:
Gender:M
Credentials:LPP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3915 GOLDEN VALLEY ROAD
Mailing Address - Street 2:COURAGE CENTER
Mailing Address - City:GOLDEN VALLEY
Mailing Address - State:MN
Mailing Address - Zip Code:55422
Mailing Address - Country:US
Mailing Address - Phone:763-520-0516
Mailing Address - Fax:
Practice Address - Street 1:3915 GOLDEN VALLEY ROAD
Practice Address - Street 2:COURAGE CENTER
Practice Address - City:GOLDEN VALLEY
Practice Address - State:MN
Practice Address - Zip Code:55422
Practice Address - Country:US
Practice Address - Phone:763-520-0516
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-05-19
Last Update Date:2008-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLPP 0117103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling