MEDICARE: CRYSTA ROCHELE CADALBERT LADC

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	307129	MN

General Provider Information

NPI Number	:	1447084884
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CRYSTA ROCHELE CADALBERT LADC

Provider Business Mailing Address
First Line	:	9201 75TH AVE N
Second Line	:
City	:	BROOKLYN PARK
State	:	MN
Zip	:	55428-1024
Country	:	US
Telephone Number	:	763-315-7170
Fax Number	:	763-315-7177

Provider Business Practice Location Address
First Line	:	9201 75TH AVE N
Second Line	:
City	:	BROOKLYN PARK
State	:	MN
Zip	:	55428-1024
Country	:	US
Telephone Number	:	763-315-7170
Fax Number	:	763-315-7177

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/28/2024
Last Update Date	:	08/28/2024

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