Provider Demographics
NPI:1932614518
Name:POEHLER, MELISSA ANN (LADC)
Entity type:Individual
Prefix:
First Name:MELISSA
Middle Name:ANN
Last Name:POEHLER
Suffix:
Gender:F
Credentials:LADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:410 MARTIN AVE
Mailing Address - Street 2:
Mailing Address - City:BIG LAKE
Mailing Address - State:MN
Mailing Address - Zip Code:55309-8004
Mailing Address - Country:US
Mailing Address - Phone:763-607-6344
Mailing Address - Fax:
Practice Address - Street 1:410 MARTIN AVE
Practice Address - Street 2:
Practice Address - City:BIG LAKE
Practice Address - State:MN
Practice Address - Zip Code:55309-8004
Practice Address - Country:US
Practice Address - Phone:763-607-6344
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-12-05
Last Update Date:2017-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN302424101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN302424OtherMN BOARD OF BEHAVIORAL HEALTH LICENSE