Provider Demographics
NPI:1609381557
Name:THELEN, NICHOLAS (MA LADC)
Entity Type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:
Last Name:THELEN
Suffix:
Gender:M
Credentials:MA LADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2311 WOODBRIDGE ST
Mailing Address - Street 2:
Mailing Address - City:ROSEVILLE
Mailing Address - State:MN
Mailing Address - Zip Code:55113-4710
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2311 WOODBRIDGE ST
Practice Address - Street 2:
Practice Address - City:ROSEVILLE
Practice Address - State:MN
Practice Address - Zip Code:55113-4710
Practice Address - Country:US
Practice Address - Phone:651-773-0832
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-12-13
Last Update Date:2017-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN303546101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)