Provider Demographics
NPI:1316059074
Name:HUNTLEY, MICHAEL K (MA LP)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:K
Last Name:HUNTLEY
Suffix:
Gender:M
Credentials:MA LP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:101 W PINE ST
Mailing Address - Street 2:
Mailing Address - City:STILLWATER
Mailing Address - State:MN
Mailing Address - Zip Code:55082
Mailing Address - Country:US
Mailing Address - Phone:651-439-8800
Mailing Address - Fax:651-439-1040
Practice Address - Street 1:101 W PINE ST
Practice Address - Street 2:
Practice Address - City:STILLWATER
Practice Address - State:MN
Practice Address - Zip Code:55082
Practice Address - Country:US
Practice Address - Phone:651-439-8800
Practice Address - Fax:651-439-1040
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP0420103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNA3K670HUOtherBCBS
MN13K671HUOtherBCBS
MN411333578002OtherCHAMPUS TRI-CARE