Provider Demographics
NPI:1093288987
Name:SEDLACEK, LAWRENCE LOWELL (MA LADC)
Entity Type:Individual
Prefix:
First Name:LAWRENCE
Middle Name:LOWELL
Last Name:SEDLACEK
Suffix:
Gender:M
Credentials:MA LADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1821 UNIVERSITY AVE W STE N385
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55104-2872
Mailing Address - Country:US
Mailing Address - Phone:612-454-2447
Mailing Address - Fax:651-647-9147
Practice Address - Street 1:2785 WHITE BEAR AVE N STE 403
Practice Address - Street 2:
Practice Address - City:MAPLEWOOD
Practice Address - State:MN
Practice Address - Zip Code:55109-1327
Practice Address - Country:US
Practice Address - Phone:651-395-5787
Practice Address - Fax:651-647-9147
Is Sole Proprietor?:No
Enumeration Date:2019-01-03
Last Update Date:2023-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN305266101YA0400X
MNCC03838101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN205557491Medicaid