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 1:1370 MENDOTA HEIGHTS RD
Mailing Address - Street 2:
Mailing Address - City:MENDOTA HEIGHTS
Mailing Address - State:MN
Mailing Address - Zip Code:55120-1281
Mailing Address - Country:US
Mailing Address - Phone:651-313-8080
Mailing Address - Fax:
Practice Address - Street 1:4570 CHURCHILL ST STE 300
Practice Address - Street 2:
Practice Address - City:SHOREVIEW
Practice Address - State:MN
Practice Address - Zip Code:55126-2274
Practice Address - Country:US
Practice Address - Phone:651-313-8080
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-05-02
Last Update Date:2024-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN304326101YA0400X
101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)