=====================================================
General NPI Number Information
=====================================================
NPI Number | 1407961709
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CDC CENTERS
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/20/2006
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 15612 HIGHWAY 7 SUITE 150
-----------------------------------------------------
City | MINNETONKA
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55345-3543
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 952-894-7722
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 15612 HIGHWAY 7 SUITE 150
-----------------------------------------------------
City | MINNETONKA
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55345-3543
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 952-894-7722
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | AR MANAGER
-----------------------------------------------------
Name | MRS. DARLENE M HART
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 952-894-7722
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YA0400X
-----------------------------------------------------
Taxonomy Name | Addiction (Substance Use Disorder) Counselor
-----------------------------------------------------
License Number | 802143-1-CDT
-----------------------------------------------------
License Number State | MN
-----------------------------------------------------