Healthcare Provider Details

I. General information

NPI: 1477489698
Provider Name (Legal Business Name): GLENN RAGSDALE NUCKOLS LADC, LPCC
Entity Type: Individual
Gender:
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/23/2026
Last Update Date: 06/23/2026
Certification Date: 06/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4749 CHICAGO AVE STE 2B
MINNEAPOLIS MN
55407-4181
US

IV. Provider business mailing address

4749 CHICAGO AVE STE 2B
MINNEAPOLIS MN
55407-4181
US

V. Phone/Fax

Practice location:
  • Phone: 612-361-7885
  • Fax:
Mailing address:
  • Phone: 612-361-7885
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number306818
License Number StateMN
# 2
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number5648
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: