Provider Demographics
NPI:1477280501
Name:ROMMEL, MATTHEW JOSEPH (LADC)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:JOSEPH
Last Name:ROMMEL
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 1:2050 COUNTY ROAD F E APT 7
Mailing Address - Street 2:
Mailing Address - City:WHITE BEAR LAKE
Mailing Address - State:MN
Mailing Address - Zip Code:55110-3884
Mailing Address - Country:US
Mailing Address - Phone:612-386-7222
Mailing Address - Fax:
Practice Address - Street 1:2483 15TH ST NW STE A
Practice Address - Street 2:
Practice Address - City:NEW BRIGHTON
Practice Address - State:MN
Practice Address - Zip Code:55112-5604
Practice Address - Country:US
Practice Address - Phone:612-756-9107
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-08-08
Last Update Date:2022-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN305790101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)