=====================================================
General NPI Number Information
=====================================================
NPI Number | 1467115261
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JOHN M BRANDL LADC
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/19/2021
-----------------------------------------------------
Last Update Date | 05/29/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 201 N BROAD ST STE 200
-----------------------------------------------------
City | MANKATO
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 56001-3569
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 507-225-1500
-----------------------------------------------------
Fax | 507-225-1501
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1900 SILVER LAKE RD NW STE 110
-----------------------------------------------------
City | NEW BRIGHTON
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55112-1789
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 651-628-9566
-----------------------------------------------------
Fax | 651-628-0411
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YA0400X
-----------------------------------------------------
Taxonomy Name | Addiction (Substance Use Disorder) Counselor
-----------------------------------------------------
License Number | 305662
-----------------------------------------------------
License Number State | MN
-----------------------------------------------------