Provider Demographics
NPI:1558077222
Name:CASADAY, ROBERTA LORRAINE
Entity Type:Individual
Prefix:
First Name:ROBERTA
Middle Name:LORRAINE
Last Name:CASADAY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:206 MAPLE AVE E
Mailing Address - Street 2:
Mailing Address - City:MORA
Mailing Address - State:MN
Mailing Address - Zip Code:55051-1311
Mailing Address - Country:US
Mailing Address - Phone:320-679-3580
Mailing Address - Fax:
Practice Address - Street 1:435 BEAN AVE
Practice Address - Street 2:
Practice Address - City:MORA
Practice Address - State:MN
Practice Address - Zip Code:55051-1402
Practice Address - Country:US
Practice Address - Phone:281-491-3086
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-01-26
Last Update Date:2023-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN302270101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)