Provider Demographics
NPI:1609212398
Name:RHEAUME, BRIAN MARK (LADC)
Entity Type:Individual
Prefix:MR
First Name:BRIAN
Middle Name:MARK
Last Name:RHEAUME
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 1:7244 JACOBS ROAD
Mailing Address - Street 2:
Mailing Address - City:LAKE SHORE
Mailing Address - State:MN
Mailing Address - Zip Code:56468
Mailing Address - Country:US
Mailing Address - Phone:329-291-7625
Mailing Address - Fax:
Practice Address - Street 1:7244 JACOBS RD
Practice Address - Street 2:
Practice Address - City:LAKE SHORE
Practice Address - State:MN
Practice Address - Zip Code:56468-6871
Practice Address - Country:US
Practice Address - Phone:320-291-7625
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-05-21
Last Update Date:2013-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN302670101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)