Provider Demographics
NPI:1437868189
Name:LIDBERG, MEGHAN CHRISTINE (LADC)
Entity Type:Individual
Prefix:
First Name:MEGHAN
Middle Name:CHRISTINE
Last Name:LIDBERG
Suffix:
Gender:F
Credentials:LADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13104 XAVIS ST NW
Mailing Address - Street 2:
Mailing Address - City:COON RAPIDS
Mailing Address - State:MN
Mailing Address - Zip Code:55448-2599
Mailing Address - Country:US
Mailing Address - Phone:763-234-4051
Mailing Address - Fax:
Practice Address - Street 1:2518 1ST AVE S
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55404-4317
Practice Address - Country:US
Practice Address - Phone:651-359-2079
Practice Address - Fax:612-870-6143
Is Sole Proprietor?:No
Enumeration Date:2022-11-22
Last Update Date:2022-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN306290101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)