Healthcare Provider Details

I. General information

NPI: 1730449935
Provider Name (Legal Business Name): MELISSA M PRUDHOMME LADC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/22/2012
Last Update Date: 05/22/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1132 CENTRAL AVE NE
MINNEAPOLIS MN
55413-1512
US

IV. Provider business mailing address

1132 CENTRAL AVE NE
MINNEAPOLIS MN
55413-1512
US

V. Phone/Fax

Practice location:
  • Phone: 612-902-5932
  • Fax: 612-236-1701
Mailing address:
  • Phone: 612-902-5932
  • Fax: 612-236-1701

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number302411
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: