Provider Demographics
NPI:1831471812
Name:DANIELS, MARK RICHARD (BA, MBA, MA)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:RICHARD
Last Name:DANIELS
Suffix:
Gender:M
Credentials:BA, MBA, MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4740 144TH ST W
Mailing Address - Street 2:
Mailing Address - City:APPLE VALLEY
Mailing Address - State:MN
Mailing Address - Zip Code:55124-6996
Mailing Address - Country:US
Mailing Address - Phone:612-306-9099
Mailing Address - Fax:
Practice Address - Street 1:17113 MINNETONKA BLVD
Practice Address - Street 2:WEST ENTRANCE
Practice Address - City:MINNETONKA
Practice Address - State:MN
Practice Address - Zip Code:55345
Practice Address - Country:US
Practice Address - Phone:612-306-9099
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-15
Last Update Date:2011-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist