Healthcare Provider Details

I. General information

NPI: 1295152171
Provider Name (Legal Business Name): CYNTHIA LEE GUDAHL LADC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/27/2014
Last Update Date: 12/16/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

912 MAIN ST UNIT B
LITTLEFORK MN
56653-9379
US

IV. Provider business mailing address

912 MAIN ST UNIT B
LITTLEFORK MN
56653-9379
US

V. Phone/Fax

Practice location:
  • Phone: 218-278-4607
  • Fax: 218-278-6223
Mailing address:
  • Phone: 218-278-4607
  • Fax: 218-278-6223

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number302425
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: