=====================================================
General NPI Number Information
=====================================================
NPI Number | 1821524497
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MADISON GRUENEWALD MA, LADC
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/02/2017
-----------------------------------------------------
Last Update Date | 12/13/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4570 CHURCHILL ST STE 300
-----------------------------------------------------
City | SHOREVIEW
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55126-2274
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 651-313-8080
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1370 MENDOTA HEIGHTS RD
-----------------------------------------------------
City | MENDOTA HEIGHTS
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55120-1281
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 651-313-8080
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
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 | 304326
-----------------------------------------------------
License Number State | MN
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------