Basic Information
| Provider Information | |||||||||
| NPI: | 1477280501 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ROMMEL | ||||||||
| FirstName: | MATTHEW | ||||||||
| MiddleName: | JOSEPH | ||||||||
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| Credential: | LADC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2050 COUNTY ROAD F E APT 7 | ||||||||
| Address2: | |||||||||
| City: | WHITE BEAR LAKE | ||||||||
| State: | MN | ||||||||
| PostalCode: | 551103884 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6123867222 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 2483 15TH ST NW STE A | ||||||||
| Address2: | |||||||||
| City: | NEW BRIGHTON | ||||||||
| State: | MN | ||||||||
| PostalCode: | 551125604 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6127569107 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/08/2022 | ||||||||
| LastUpdateDate: | 08/08/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 08/08/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | 305790 | MN | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
No ID Information.