Provider Demographics
NPI:1316713241
Name:VELLINE, REBECCA LOU (LADC)
Entity type:Individual
Prefix:
First Name:REBECCA
Middle Name:LOU
Last Name:VELLINE
Suffix:
Gender:F
Credentials:LADC
Other - Prefix:
Other - First Name:REBECCA
Other - Middle Name:LOU
Other - Last Name:RONNING
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LADC
Mailing Address - Street 1:700 RAYMOND AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55114-4503
Mailing Address - Country:US
Mailing Address - Phone:218-269-2266
Mailing Address - Fax:
Practice Address - Street 1:700 RAYMOND AVE
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55114-4503
Practice Address - Country:US
Practice Address - Phone:218-269-2266
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-12-01
Last Update Date:2023-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN305375101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)