Provider Demographics
NPI:1861220121
Name:WALDEN, GARRY MICHAEL (LADC)
Entity type:Individual
Prefix:
First Name:GARRY
Middle Name:MICHAEL
Last Name:WALDEN
Suffix:
Gender:M
Credentials:LADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2961 RIVERWOOD DR
Mailing Address - Street 2:
Mailing Address - City:HASTINGS
Mailing Address - State:MN
Mailing Address - Zip Code:55033-3465
Mailing Address - Country:US
Mailing Address - Phone:651-346-8719
Mailing Address - Fax:
Practice Address - Street 1:2961 RIVERWOOD DR
Practice Address - Street 2:
Practice Address - City:HASTINGS
Practice Address - State:MN
Practice Address - Zip Code:55033-3465
Practice Address - Country:US
Practice Address - Phone:651-346-8719
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-07-26
Last Update Date:2024-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN307023101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)