Provider Demographics
NPI:1144835919
Name:CLARKLATTIMER, MELINDA JUNE
Entity type:Individual
Prefix:
First Name:MELINDA
Middle Name:JUNE
Last Name:CLARKLATTIMER
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 1:16601 RIVERWOOD DR UNIT 303
Mailing Address - Street 2:
Mailing Address - City:LITTLE FALLS
Mailing Address - State:MN
Mailing Address - Zip Code:56345-7202
Mailing Address - Country:US
Mailing Address - Phone:320-360-3611
Mailing Address - Fax:
Practice Address - Street 1:429 8TH AVE NE
Practice Address - Street 2:
Practice Address - City:BRAINERD
Practice Address - State:MN
Practice Address - Zip Code:56401-2806
Practice Address - Country:US
Practice Address - Phone:218-829-8200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-09
Last Update Date:2020-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist