Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 103TA0400X | Addiction Psychologist (Substance Use Disorder) |
NPI | 1639227135 |
---|---|
Provider Name | Jeremy William Rondorf |
First Address | Center City, MN 55012-9640 |
Second Address | Center City, MN 55012-9640 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 08/01/2007 |
Last Update Date | 11/03/2021 |