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General NPI Number Information
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NPI Number | 1205520509
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Entity Type | Individual
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Provider Name | IRENE CALLISTA ABIDE LADC
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Gender | Female
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Dates
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Enumeration Date | 06/08/2023
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Last Update Date | 06/08/2023
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Provider Practice Location Address
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Address Line | 1900 SILVER LAKE RD NW
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City | NEW BRIGHTON
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State | MN
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Zip | 55112-1786
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Country | US
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Telephone | 651-628-9566
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Fax |
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Provider Business Mailing Address
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Address Line | 2155 KELLY DR
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City | GOLDEN VALLEY
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State | MN
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Zip | 55427-3517
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Country | US
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Telephone | 763-442-2935
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YA0400X
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Taxonomy Name | Addiction (Substance Use Disorder) Counselor
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License Number |
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License Number State |
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