Provider Demographics
NPI:1962068643
Name:MACOMBER, JOSHUA ERIC (LADC)
Entity type:Individual
Prefix:MR
First Name:JOSHUA
Middle Name:ERIC
Last Name:MACOMBER
Suffix:
Gender:M
Credentials:LADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:821 E 22ND ST
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55404-2810
Mailing Address - Country:US
Mailing Address - Phone:612-708-6268
Mailing Address - Fax:
Practice Address - Street 1:2419 NICOLLET AVE
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55404-3450
Practice Address - Country:US
Practice Address - Phone:612-708-6268
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-05-17
Last Update Date:2019-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN305344101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)