Healthcare Provider Details

I. General information

NPI: 1780409276
Provider Name (Legal Business Name): CHRISTY LEVELL DUPREE LADC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/19/2024
Last Update Date: 11/19/2024
Certification Date: 11/19/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11010 PRAIRIE LAKES DR STE 350
EDEN PRAIRIE MN
55344-3801
US

IV. Provider business mailing address

7501 W 101ST ST APT 107
BLOOMINGTON MN
55438-2518
US

V. Phone/Fax

Practice location:
  • Phone: 952-234-8606
  • Fax: 952-746-0887
Mailing address:
  • Phone: 612-986-2127
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number306807
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: