Provider Demographics
NPI:1134556921
Name:TERESA, MARK
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:TERESA
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 1:681 17TH AVE NE
Mailing Address - Street 2:SUITE 312
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55413-4590
Mailing Address - Country:US
Mailing Address - Phone:612-876-5917
Mailing Address - Fax:
Practice Address - Street 1:681 17TH AVE NE
Practice Address - Street 2:SUITE 312
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55413-4590
Practice Address - Country:US
Practice Address - Phone:612-876-5917
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-10-11
Last Update Date:2013-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2584106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist