Provider Demographics
NPI:1689147654
Name:RENKEN, MATTHEW (LADC)
Entity type:Individual
Prefix:MR
First Name:MATTHEW
Middle Name:
Last Name:RENKEN
Suffix:
Gender:
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:PO BOX 206
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55480-0206
Mailing Address - Country:US
Mailing Address - Phone:612-262-9000
Mailing Address - Fax:
Practice Address - Street 1:520 OSBORNE RD NE STE 210
Practice Address - Street 2:
Practice Address - City:FRIDLEY
Practice Address - State:MN
Practice Address - Zip Code:55432-2718
Practice Address - Country:US
Practice Address - Phone:763-236-3800
Practice Address - Fax:763-236-3821
Is Sole Proprietor?:No
Enumeration Date:2019-01-02
Last Update Date:2025-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN4234101YP2500X
101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional