Provider Demographics
NPI:1821524497
Name:GRUENEWALD, MADISON (MA, LADC)
Entity Type:Individual
Prefix:
First Name:MADISON
Middle Name:
Last Name:GRUENEWALD
Suffix:
Gender:F
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 1:10255 GRAND ISLE PL
Mailing Address - Street 2:
Mailing Address - City:WOODBURY
Mailing Address - State:MN
Mailing Address - Zip Code:55129-4231
Mailing Address - Country:US
Mailing Address - Phone:651-366-1546
Mailing Address - Fax:
Practice Address - Street 1:11010 PRAIRIE LAKES DR STE 350
Practice Address - Street 2:
Practice Address - City:EDEN PRAIRIE
Practice Address - State:MN
Practice Address - Zip Code:55344-3801
Practice Address - Country:US
Practice Address - Phone:651-366-1546
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-05-02
Last Update Date:2017-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN304326101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)