MEDICARE: MS. MARY KAY METZ 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	304011	MN

General Provider Information

NPI Number	:	1609271931
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. MARY KAY METZ LADC

Provider Business Mailing Address
First Line	:	305 30TH AVE W
Second Line	:
City	:	ALEXANDRIA
State	:	MN
Zip	:	56308-3429
Country	:	US
Telephone Number	:	320-460-8028
Fax Number	:	320-460-8029

Provider Business Practice Location Address
First Line	:	305 30TH AVE W
Second Line	:
City	:	ALEXANDRIA
State	:	MN
Zip	:	56308-3429
Country	:	US
Telephone Number	:	320-460-8028
Fax Number	:

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

Provider Enumeration Date	:	10/29/2014
Last Update Date	:	04/28/2022

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