Provider Demographics
NPI:1508233933
Name:ENSTROM PARHAM, MAUD MARIA (LADC)
Entity Type:Individual
Prefix:
First Name:MAUD
Middle Name:MARIA
Last Name:ENSTROM PARHAM
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 1:13005 COUNTY ROAD 5
Mailing Address - Street 2:
Mailing Address - City:BURNSVILLE
Mailing Address - State:MN
Mailing Address - Zip Code:55337-2226
Mailing Address - Country:US
Mailing Address - Phone:651-829-7124
Mailing Address - Fax:
Practice Address - Street 1:13005 COUNTY ROAD 5
Practice Address - Street 2:
Practice Address - City:BURNSVILLE
Practice Address - State:MN
Practice Address - Zip Code:55337-2226
Practice Address - Country:US
Practice Address - Phone:651-829-7124
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-09-02
Last Update Date:2015-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN303571101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)