MEDICARE: MELISSA ANN POEHLER 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	302424	MN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	302424	OTHER	MN	MN BOARD OF BEHAVIORAL HEALTH LICENSE

General Provider Information

NPI Number	:	1932614518
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MELISSA ANN POEHLER LADC

Provider Business Mailing Address
First Line	:	410 MARTIN AVE
Second Line	:
City	:	BIG LAKE
State	:	MN
Zip	:	55309-8004
Country	:	US
Telephone Number	:	763-607-6344
Fax Number	:

Provider Business Practice Location Address
First Line	:	410 MARTIN AVE
Second Line	:
City	:	BIG LAKE
State	:	MN
Zip	:	55309-8004
Country	:	US
Telephone Number	:	763-607-6344
Fax Number	:

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

Provider Enumeration Date	:	12/05/2017
Last Update Date	:	12/05/2017

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