Provider Demographics
NPI:1669787628
Name:MARTIN, MINDY ANN
Entity type:Individual
Prefix:
First Name:MINDY
Middle Name:ANN
Last Name:MARTIN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:308 12TH AVE S
Mailing Address - Street 2:
Mailing Address - City:BUFFALO
Mailing Address - State:MN
Mailing Address - Zip Code:55313-2321
Mailing Address - Country:US
Mailing Address - Phone:763-682-4400
Mailing Address - Fax:763-682-1353
Practice Address - Street 1:1321 13TH ST N
Practice Address - Street 2:
Practice Address - City:SAINT CLOUD
Practice Address - State:MN
Practice Address - Zip Code:56303-2613
Practice Address - Country:US
Practice Address - Phone:320-252-5010
Practice Address - Fax:320-203-1855
Is Sole Proprietor?:No
Enumeration Date:2010-08-16
Last Update Date:2010-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)