Most Relevant Information
Provider Data
| NPI Number: | 1003486564 |
| Provider Name: | MYSTIC MAKEPEACE |
| Entity Type: | Individual |
| Taxonomy Code: | 106S00000X |
| Specialty: | Behavior Technician |
| License Number: |
Most Important Dates
| Enumeration Date: | 06/28/2021 |
| Last Updated: | 06/28/2021 |
Provider Practice Location
3333 UNIVERSITY AVE SE
MINNEAPOLIS
MN
554143325
Practice Location Phone/Fax
| Phone: | 6127677222 |
| Fax: |
Provider Mailing Location
1564 RANDOLPH AVE APT 202
SAINT PAUL
MN
551052541
Provider Mailing Phone/Fax
| Phone: | 6128453750 |
| Fax: |