Healthcare Provider Details

I. General information

NPI: 1982937546
Provider Name (Legal Business Name): CALLEE RAE NOLDEN LADC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/15/2009
Last Update Date: 10/27/2020
Certification Date: 10/27/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1406 6TH AVE N
SAINT CLOUD MN
56303-1901
US

IV. Provider business mailing address

1406 6TH AVE N
SAINT CLOUD MN
56303-1901
US

V. Phone/Fax

Practice location:
  • Phone: 320-251-2700
  • Fax: 320-656-7106
Mailing address:
  • Phone: 320-251-2700
  • Fax: 320-656-7106

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number1010
License Number StateMT
# 2
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number302959
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: