MEDICARE: PROVIDENCE 99:1

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YA0400X	Addiction (Substance Use Disorder) Counselor

General Provider Information

NPI Number	:	1023952314
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PROVIDENCE 99:1

Provider Business Mailing Address
First Line	:	649 OLD HIGHWAY 8 NW APT 339
Second Line	:
City	:	NEW BRIGHTON
State	:	MN
Zip	:	55112-2873
Country	:	US
Telephone Number	:	651-815-9714
Fax Number	:

Provider Business Practice Location Address
First Line	:	1330 LAGOON AVE FL 4
Second Line	:
City	:	MINNEAPOLIS
State	:	MN
Zip	:	55408-2885
Country	:	US
Telephone Number	:	651-815-9714
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	CRYSTA CADALBERT CADALBERT
Credential	:	LADC
Telephone Number	:	651-815-9714

Provider Enumeration Date	:	04/16/2026
Last Update Date	:	04/16/2026

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