Provider Demographics
NPI:1306247531
Name:THEISEN, JULIE ANN (LADC)
Entity type:Individual
Prefix:MS
First Name:JULIE
Middle Name:ANN
Last Name:THEISEN
Suffix:
Gender:F
Credentials:LADC
Other - Prefix:
Other - First Name:JULIE
Other - Middle Name:ANN
Other - Last Name:STANGEL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:(PRIOR TO LADC)
Mailing Address - Street 1:2351 3RD STREET NW
Mailing Address - Street 2:201
Mailing Address - City:NEW BRIGHTON
Mailing Address - State:MN
Mailing Address - Zip Code:55112
Mailing Address - Country:US
Mailing Address - Phone:612-559-6250
Mailing Address - Fax:
Practice Address - Street 1:2351 3RD STREET NW
Practice Address - Street 2:201
Practice Address - City:NEW BRIGHTON
Practice Address - State:MN
Practice Address - Zip Code:55112
Practice Address - Country:US
Practice Address - Phone:612-559-6250
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-09-08
Last Update Date:2014-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN303869101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)