Provider Demographics
NPI:1639615800
Name:MEDNICK, JUSTIN MICHAEL
Entity Type:Individual
Prefix:
First Name:JUSTIN
Middle Name:MICHAEL
Last Name:MEDNICK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7600 PARKLAWN AVE
Mailing Address - Street 2:380
Mailing Address - City:EDINA
Mailing Address - State:MN
Mailing Address - Zip Code:55435-5125
Mailing Address - Country:US
Mailing Address - Phone:612-203-2961
Mailing Address - Fax:952-831-0033
Practice Address - Street 1:101 5TH ST E
Practice Address - Street 2:208
Practice Address - City:NORTHFIELD
Practice Address - State:MN
Practice Address - Zip Code:55057-2067
Practice Address - Country:US
Practice Address - Phone:507-222-9230
Practice Address - Fax:507-786-9877
Is Sole Proprietor?:No
Enumeration Date:2017-01-12
Last Update Date:2017-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health