Basic Information
| Provider Information | |||||||||
| NPI: | 1760092712 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PACHECO | ||||||||
| FirstName: | ADRIENNE | ||||||||
| MiddleName: | MARIE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1604 HAMPSHIRE AVE S | ||||||||
| Address2: | |||||||||
| City: | ST LOUIS PARK | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554262133 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9527973910 | ||||||||
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| Practice Location | |||||||||
| Address1: | 3333 UNIVERSITY AVE SE | ||||||||
| Address2: | |||||||||
| City: | MINNEAPOLIS | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554143325 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6127677222 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/05/2020 | ||||||||
| LastUpdateDate: | 08/09/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 08/09/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106S00000X | MN | N | 103K00000X | 1-22-59331 | MN | Y | Behavioral Health & Social Service Providers | Behavioral Analyst |
No ID Information.