Healthcare Provider Details

I. General information

NPI: 1215537477
Provider Name (Legal Business Name): HANNAH MAE KIDDER LADC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: HANNAH MAE FORNEY LADC

II. Dates (important events)

Enumeration Date: 10/27/2020
Last Update Date: 10/17/2024
Certification Date: 10/17/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6040 EARLE BROWN DR STE 100
BROOKLYN CENTER MN
55430-2561
US

IV. Provider business mailing address

1370 MENDOTA HEIGHTS RD
MENDOTA HEIGHTS MN
55120-1281
US

V. Phone/Fax

Practice location:
  • Phone: 651-313-8080
  • Fax:
Mailing address:
  • Phone: 651-313-8080
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number303758
License Number StateMN
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number4470
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: