Provider Demographics
NPI:1295152171
Name:GUDAHL, CYNTHIA LEE (LADC)
Entity type:Individual
Prefix:
First Name:CYNTHIA
Middle Name:LEE
Last Name:GUDAHL
Suffix:
Gender:F
Credentials:LADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:912 MAIN ST UNIT B
Mailing Address - Street 2:
Mailing Address - City:LITTLEFORK
Mailing Address - State:MN
Mailing Address - Zip Code:56653-9379
Mailing Address - Country:US
Mailing Address - Phone:218-278-4607
Mailing Address - Fax:218-278-6223
Practice Address - Street 1:912 MAIN ST UNIT B
Practice Address - Street 2:
Practice Address - City:LITTLEFORK
Practice Address - State:MN
Practice Address - Zip Code:56653-9379
Practice Address - Country:US
Practice Address - Phone:218-278-4607
Practice Address - Fax:218-278-6223
Is Sole Proprietor?:No
Enumeration Date:2014-03-27
Last Update Date:2016-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN302425101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)