Healthcare Provider Details

I. General information

NPI: 1457030009
Provider Name (Legal Business Name): MARY J STADLER MA, LPCC, LADC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/12/2023
Last Update Date: 07/12/2023
Certification Date: 07/12/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1619 PORTLAND AVE
MINNEAPOLIS MN
55404-1507
US

IV. Provider business mailing address

740 E 24TH ST
MINNEAPOLIS MN
55404-3862
US

V. Phone/Fax

Practice location:
  • Phone: 612-238-6536
  • Fax: 612-333-4111
Mailing address:
  • Phone: 612-373-3366
  • Fax: 612-333-4111

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberCC03934
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: