Healthcare Provider Details

I. General information

NPI: 1407406754
Provider Name (Legal Business Name): PAULA KAY ROULAND LADC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/18/2019
Last Update Date: 01/13/2025
Certification Date: 01/13/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3701 12TH ST N
SAINT CLOUD MN
56303-2255
US

IV. Provider business mailing address

3701 12TH ST N
SAINT CLOUD MN
56303-2255
US

V. Phone/Fax

Practice location:
  • Phone: 320-229-3760
  • Fax: 320-229-3763
Mailing address:
  • Phone: 320-229-3760
  • Fax: 320-229-3763

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number302008
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: