Healthcare Provider Details

I. General information

NPI: 1255205035
Provider Name (Legal Business Name): MACY J METERAUD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/03/2025
Last Update Date: 10/03/2025
Certification Date: 10/03/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4000 W 9TH ST
DULUTH MN
55807-1563
US

IV. Provider business mailing address

7293 S KIP RD
SOUTH RANGE WI
54874-8307
US

V. Phone/Fax

Practice location:
  • Phone: 218-625-2656
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number31066
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: