Provider Demographics
NPI:1316445455
Name:NORTHERN WATERS CLINIC, PLLC
Entity type:Organization
Organization Name:NORTHERN WATERS CLINIC, PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CO-OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MELISSA
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:MAKI
Authorized Official - Suffix:
Authorized Official - Credentials:NP
Authorized Official - Phone:218-727-3888
Mailing Address - Street 1:1702 MILLER TRUNK HWY STE 214
Mailing Address - Street 2:
Mailing Address - City:DULUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55811-4443
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4899 MILLER TRUNK HWY STE 208
Practice Address - Street 2:
Practice Address - City:HERMANTOWN
Practice Address - State:MN
Practice Address - Zip Code:55811-1582
Practice Address - Country:US
Practice Address - Phone:218-391-9860
Practice Address - Fax:218-391-9860
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-01-23
Last Update Date:2021-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2318163WP0807X, 163WP0808X
261QM0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No163WP0807XNursing Service ProvidersRegistered NursePsychiatric/Mental Health, Child & AdolescentGroup - Multi-Specialty
No163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental HealthGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN1295014520Medicaid