Basic Information
| Provider Information | |||||||||
| NPI: | 1134271653 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WELCH | ||||||||
| FirstName: | CHESTER | ||||||||
| MiddleName: | ORLAND | ||||||||
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| Credential: | LADC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 20 BURGER DR | ||||||||
| Address2: | |||||||||
| City: | DULUTH | ||||||||
| State: | MN | ||||||||
| PostalCode: | 558081922 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2186262395 | ||||||||
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| Practice Location | |||||||||
| Address1: | 927 TRETTEL LN | ||||||||
| Address2: | FOND DU LAC HUMAN SERVICES DIVISION | ||||||||
| City: | CLOQUET | ||||||||
| State: | MN | ||||||||
| PostalCode: | 557201345 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2188791227 | ||||||||
| FaxNumber: | 2188782188 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/17/2007 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | 300211 | MN | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
ID Information
| ID | Type | State | Issuer | Description | NPP000 | 01 | MN | FDLHSD UPIN | OTHER |