Healthcare Provider Details

I. General information

NPI: 1023798840
Provider Name (Legal Business Name): AVRIELLE JEWEL SCHNEIDER LADC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/18/2023
Last Update Date: 07/18/2023
Certification Date: 07/18/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1215 SE 7TH AVE
GRAND RAPIDS MN
55744-4201
US

IV. Provider business mailing address

1215 SE 7TH AVE
GRAND RAPIDS MN
55744-4201
US

V. Phone/Fax

Practice location:
  • Phone: 218-327-1105
  • Fax: 218-327-1932
Mailing address:
  • Phone: 218-327-1105
  • Fax: 218-327-1932

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TA0400X
TaxonomyAddiction (Substance Use Disorder) Psychologist
License Number306658
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: