Healthcare Provider Details

I. General information

NPI: 1346603503
Provider Name (Legal Business Name): SHAWNA VELDHUIZEN LADC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: SHAWNA HARTOG

II. Dates (important events)

Enumeration Date: 04/04/2016
Last Update Date: 04/04/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16201 90TH STREET NW, SUITE 200
OTSEGO MN
55330
US

IV. Provider business mailing address

1900 SILVER LAKE ROAD NW SUITE 110
NEW BRIGHTON MN
55112
US

V. Phone/Fax

Practice location:
  • Phone: 763-746-9492
  • Fax: 763-746-3685
Mailing address:
  • Phone: 651-379-1718
  • Fax: 651-379-1738

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number300863
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: