Healthcare Provider Details

I. General information

NPI: 1871441469
Provider Name (Legal Business Name): THADIOUS WALKER LADC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/19/2026
Last Update Date: 03/19/2026
Certification Date: 03/19/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8550 HUDSON BLVD N
LAKE ELMO MN
55042-5500
US

IV. Provider business mailing address

5750 SANDER DR APT 3
MINNEAPOLIS MN
55417-2841
US

V. Phone/Fax

Practice location:
  • Phone: 651-254-8580
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number307575
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: