Healthcare Provider Details

I. General information

NPI: 1780101188
Provider Name (Legal Business Name): DANIELLE RAE SPOLARICH LPC, LADC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/25/2017
Last Update Date: 08/25/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

505 S 12TH AVE W
VIRGINIA MN
55792-3099
US

IV. Provider business mailing address

505 S 12TH AVE W
VIRGINIA MN
55792-3099
US

V. Phone/Fax

Practice location:
  • Phone: 12187492877127
  • Fax: 218-749-6033
Mailing address:
  • Phone: 12187492877127
  • Fax: 218-749-6033

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number1862
License Number StateMN
# 2
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number309494
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: