Healthcare Provider Details

I. General information

NPI: 1639701782
Provider Name (Legal Business Name): ALISHA DYBEDAHL LADC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/06/2020
Last Update Date: 02/06/2020
Certification Date: 02/06/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15251 PLEASANT VALLEY RD
CENTER CITY MN
55012-9640
US

IV. Provider business mailing address

2019 57TH ST
SOMERSET WI
54025-7271
US

V. Phone/Fax

Practice location:
  • Phone: 651-213-4294
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number304810
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: