Healthcare Provider Details

I. General information

NPI: 1033627716
Provider Name (Legal Business Name): NICHOLAS WEIDNER
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/17/2018
Last Update Date: 04/25/2026
Certification Date: 04/25/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

860 BLUE GENTIAN RD STE 200
EAGAN MN
55121-1567
US

IV. Provider business mailing address

13288 BRASS PKWY
ROSEMOUNT MN
55068-2772
US

V. Phone/Fax

Practice location:
  • Phone: 651-315-5274
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number304455
License Number StateMN
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberCC1831
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: