Provider Demographics
NPI:1487169488
Name:HARTWIG, ELISSA L (LADC)
Entity type:Individual
Prefix:
First Name:ELISSA
Middle Name:L
Last Name:HARTWIG
Suffix:
Gender:F
Credentials:LADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15940 PINE SHORES RD
Mailing Address - Street 2:
Mailing Address - City:BRAINERD
Mailing Address - State:MN
Mailing Address - Zip Code:56401-5827
Mailing Address - Country:US
Mailing Address - Phone:218-831-3043
Mailing Address - Fax:
Practice Address - Street 1:15940 PINE SHORES RD
Practice Address - Street 2:
Practice Address - City:BRAINERD
Practice Address - State:MN
Practice Address - Zip Code:56401-5827
Practice Address - Country:US
Practice Address - Phone:218-831-3043
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-12-12
Last Update Date:2017-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN303653101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)