Provider Demographics
NPI:1417794868
Name:VENNEVOLD, RICHARD
Entity type:Individual
Prefix:
First Name:RICHARD
Middle Name:
Last Name:VENNEVOLD
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3611 MUNGER SHAW RD
Mailing Address - Street 2:
Mailing Address - City:CLOQUET
Mailing Address - State:MN
Mailing Address - Zip Code:55720-8215
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:205 W 2ND ST STE 150
Practice Address - Street 2:
Practice Address - City:DULUTH
Practice Address - State:MN
Practice Address - Zip Code:55802-1920
Practice Address - Country:US
Practice Address - Phone:218-748-8500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-07-12
Last Update Date:2024-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician