Healthcare Provider Details

I. General information

NPI: 1780590455
Provider Name (Legal Business Name): DANIEL JAMES DWYER LADC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/21/2026
Last Update Date: 08/21/2026
Certification Date: 08/21/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3012 CLINTON AVE STE 1
MINNEAPOLIS MN
55408-2421
US

IV. Provider business mailing address

9901 PILLSBURY AVE S
BLOOMINGTON MN
55420-4822
US

V. Phone/Fax

Practice location:
  • Phone: 612-508-8704
  • Fax:
Mailing address:
  • Phone: 651-592-9886
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number305337
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: