Healthcare Provider Details

I. General information

NPI: 1245968940
Provider Name (Legal Business Name): CALISSA KATHLEEN PLOCHARSKI LADC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/10/2022
Last Update Date: 08/10/2022
Certification Date: 08/10/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2118 BLAISDELL AVE
MINNEAPOLIS MN
55404-2415
US

IV. Provider business mailing address

2118 BLAISDELL AVE
MINNEAPOLIS MN
55404-2415
US

V. Phone/Fax

Practice location:
  • Phone: 612-235-4501
  • Fax:
Mailing address:
  • Phone: 612-235-4581
  • Fax: 612-872-8855

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: