Provider Demographics
NPI:1114692092
Name:GUDAHL, JOHN THEODORE (LADC)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:THEODORE
Last Name:GUDAHL
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 1:5633 WHITE OAKS LN NW
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:MN
Mailing Address - Zip Code:55901-3778
Mailing Address - Country:US
Mailing Address - Phone:218-341-4527
Mailing Address - Fax:
Practice Address - Street 1:300 11TH AVE NW STE 112
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:MN
Practice Address - Zip Code:55901-2739
Practice Address - Country:US
Practice Address - Phone:507-216-6500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-12
Last Update Date:2021-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN305754101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)