Provider Demographics
NPI:1225679053
Name:EDSTROM, KRISTINE LEE (LPCC)
Entity Type:Individual
Prefix:
First Name:KRISTINE
Middle Name:LEE
Last Name:EDSTROM
Suffix:
Gender:F
Credentials:LPCC
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 498
Mailing Address - Street 2:
Mailing Address - City:BIWABIK
Mailing Address - State:MN
Mailing Address - Zip Code:55708-0498
Mailing Address - Country:US
Mailing Address - Phone:218-591-6023
Mailing Address - Fax:
Practice Address - Street 1:504 S 2ND AVE
Practice Address - Street 2:
Practice Address - City:VIRGINIA
Practice Address - State:MN
Practice Address - Zip Code:55792
Practice Address - Country:US
Practice Address - Phone:218-212-5700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-10-02
Last Update Date:2022-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2875101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN2875OtherMN BOARD OF BEHAVIORAL HEALTH AND THERAPY