=====================================================
General NPI Number Information
=====================================================
NPI Number | 1962298224
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DEVIN LANI WERTHAUSER LADC
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/15/2025
-----------------------------------------------------
Last Update Date | 04/15/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6916 LAKE TER E
-----------------------------------------------------
City | WOODBURY
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55125-3966
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 651-204-8683
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2154 CHARLTON RD
-----------------------------------------------------
City | SUNFISH LAKE
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55118-4737
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 651-276-9314
-----------------------------------------------------
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 | 307011
-----------------------------------------------------
License Number State | MN
-----------------------------------------------------