Provider Demographics
NPI:1003933532
Name:LISTIAK, ALAN M
Entity Type:Individual
Prefix:MR
First Name:ALAN
Middle Name:M
Last Name:LISTIAK
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 1:2712 FREMONT AVE S
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55408-1122
Mailing Address - Country:US
Mailing Address - Phone:612-822-1357
Mailing Address - Fax:612-822-1360
Practice Address - Street 1:1516 W LAKE ST
Practice Address - Street 2:SUITE 103
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55408-2554
Practice Address - Country:US
Practice Address - Phone:612-822-1357
Practice Address - Fax:612-822-1360
Is Sole Proprietor?:No
Enumeration Date:2007-03-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN77671041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NONEOtherNONE