1235671306 NPI number — MEGAN MARIE RADOSEVICH MA, LPCC

Table of content: MEGAN MARIE RADOSEVICH MA, LPCC (NPI 1235671306)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1235671306 NPI number — MEGAN MARIE RADOSEVICH MA, LPCC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
RADOSEVICH
Provider First Name:
MEGAN
Provider Middle Name:
MARIE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MA, LPCC
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
GORMAN
Provider Other First Name:
MEGAN
Provider Other Middle Name:
MARIE
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1235671306
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/23/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
300 1ST AVE NW STE 210
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ROCHESTER
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55901-2830
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
507-398-3394
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
300 1ST AVE NW STE 210
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ROCHESTER
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55901-2830
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
507-398-3394
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
11/07/2016

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 101YM0800X , with the licence number:  CC01347 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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