Provider Demographics
NPI:1760092712
Name:PACHECO, ADRIENNE MARIE
Entity Type:Individual
Prefix:
First Name:ADRIENNE
Middle Name:MARIE
Last Name:PACHECO
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 1:5742 SUMTER AVE N
Mailing Address - Street 2:
Mailing Address - City:CRYSTAL
Mailing Address - State:MN
Mailing Address - Zip Code:55428-3313
Mailing Address - Country:US
Mailing Address - Phone:952-797-3910
Mailing Address - Fax:
Practice Address - Street 1:302 WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:MONTICELLO
Practice Address - State:MN
Practice Address - Zip Code:55362-8812
Practice Address - Country:US
Practice Address - Phone:763-272-2050
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-05
Last Update Date:2023-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN106S00000X
MN1-22-59331103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician