Provider Demographics
NPI:1891297024
Name:NORDLUM, ALICE ETHEL
Entity type:Individual
Prefix:
First Name:ALICE
Middle Name:ETHEL
Last Name:NORDLUM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1175 N RYAN LAKE RD NE
Mailing Address - Street 2:
Mailing Address - City:ISANTI
Mailing Address - State:MN
Mailing Address - Zip Code:55040-6146
Mailing Address - Country:US
Mailing Address - Phone:763-607-7284
Mailing Address - Fax:
Practice Address - Street 1:5842 OLD MAIN ST STE 2
Practice Address - Street 2:
Practice Address - City:NORTH BRANCH
Practice Address - State:MN
Practice Address - Zip Code:55056-6687
Practice Address - Country:US
Practice Address - Phone:651-401-3068
Practice Address - Fax:651-674-2534
Is Sole Proprietor?:No
Enumeration Date:2018-03-04
Last Update Date:2018-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN304361101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)