Provider Demographics
NPI:1255205035
Name:METERAUD, MACY J
Entity type:Individual
Prefix:
First Name:MACY
Middle Name:J
Last Name:METERAUD
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7293 S KIP RD
Mailing Address - Street 2:
Mailing Address - City:SOUTH RANGE
Mailing Address - State:WI
Mailing Address - Zip Code:54874-8307
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4000 W 9TH ST
Practice Address - Street 2:
Practice Address - City:DULUTH
Practice Address - State:MN
Practice Address - Zip Code:55807-1563
Practice Address - Country:US
Practice Address - Phone:218-625-2656
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-10-03
Last Update Date:2025-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN31066101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health