Healthcare Provider Details

I. General information

NPI: 1093157471
Provider Name (Legal Business Name): KELLY METTAYER LADC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/25/2013
Last Update Date: 07/23/2026
Certification Date: 07/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7066 STILLWATER BLVD N STE 110
OAKDALE MN
55128-3937
US

IV. Provider business mailing address

7066 STILLWATER BLVD N
OAKDALE MN
55128-3937
US

V. Phone/Fax

Practice location:
  • Phone: 763-324-4533
  • Fax:
Mailing address:
  • Phone: 763-324-4533
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number301614
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: