Provider Demographics
NPI:1376633743
Name:ADDICTION COUNSELING TREATMENT SERVICES
Entity Type:Organization
Organization Name:ADDICTION COUNSELING TREATMENT SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:J
Authorized Official - Last Name:RUESGEN
Authorized Official - Suffix:
Authorized Official - Credentials:LADC
Authorized Official - Phone:507-237-2716
Mailing Address - Street 1:112 5TH ST.
Mailing Address - Street 2:P.O. BOX 700
Mailing Address - City:GAYLORD
Mailing Address - State:MN
Mailing Address - Zip Code:55334
Mailing Address - Country:US
Mailing Address - Phone:507-238-2716
Mailing Address - Fax:507-237-2736
Practice Address - Street 1:112 5TH ST.
Practice Address - Street 2:
Practice Address - City:GAYLORD
Practice Address - State:MN
Practice Address - Zip Code:55334
Practice Address - Country:US
Practice Address - Phone:507-238-2716
Practice Address - Fax:507-237-2736
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-13
Last Update Date:2008-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN10422051CDT101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN340090500Medicaid