Healthcare Provider Details

I. General information

NPI: 1962940338
Provider Name (Legal Business Name): AMBASSADORS FOR SPIRITUAL & MENTAL WELLNESS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/06/2017
Last Update Date: 09/01/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

23 MINNESOTA ST S
NEW ULM MN
56073
US

IV. Provider business mailing address

23 MINNESOTA ST. S PO BOX 68
NEW ULM MN
56073
US

V. Phone/Fax

Practice location:
  • Phone: 507-359-7101
  • Fax: 651-323-2053
Mailing address:
  • Phone: 507-359-7101
  • Fax: 651-323-2053

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number1085116-1-SUDX
License Number StateMN
# 2
Primary TaxonomyN
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number21041
License Number StateMN

VIII. Authorized Official

Name: WADE LYNN LANG
Title or Position: EXECUTIVE DIRECTOR
Credential: LPCC, LADC
Phone: 507-359-7101