Provider Demographics
NPI:1457817330
Name:KRIESEL, JUDY (LADC)
Entity Type:Individual
Prefix:
First Name:JUDY
Middle Name:
Last Name:KRIESEL
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 1:2215 6TH ST S
Mailing Address - Street 2:
Mailing Address - City:BRAINERD
Mailing Address - State:MN
Mailing Address - Zip Code:56401-5549
Mailing Address - Country:US
Mailing Address - Phone:218-454-3269
Mailing Address - Fax:218-454-3151
Practice Address - Street 1:2215 S 6TH ST
Practice Address - Street 2:
Practice Address - City:BRAINERD
Practice Address - State:MN
Practice Address - Zip Code:56401-5549
Practice Address - Country:US
Practice Address - Phone:218-454-3269
Practice Address - Fax:218-454-3151
Is Sole Proprietor?:No
Enumeration Date:2019-02-15
Last Update Date:2019-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN303484101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)