MEDICARE: MADISON GRUENEWALD MA, LADC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YA0400X	Addiction (Substance Use Disorder) Counselor	304326	MN
2	101YP2500X	Professional Counselor

General Provider Information

NPI Number	:	1821524497
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MADISON GRUENEWALD MA, LADC

Provider Business Mailing Address
First Line	:	1370 MENDOTA HEIGHTS RD
Second Line	:
City	:	MENDOTA HEIGHTS
State	:	MN
Zip	:	55120-1281
Country	:	US
Telephone Number	:	651-313-8080
Fax Number	:

Provider Business Practice Location Address
First Line	:	4570 CHURCHILL ST STE 300
Second Line	:
City	:	SHOREVIEW
State	:	MN
Zip	:	55126-2274
Country	:	US
Telephone Number	:	651-313-8080
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/02/2017
Last Update Date	:	12/13/2024

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