Provider Demographics
NPI:1437824539
Name:ITES, HEATHER (LPCC, LADC)
Entity Type:Individual
Prefix:
First Name:HEATHER
Middle Name:
Last Name:ITES
Suffix:
Gender:F
Credentials:LPCC, LADC
Other - Prefix:
Other - First Name:HEATHER
Other - Middle Name:
Other - Last Name:BROVOLD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:69 HATCH AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55117-4938
Mailing Address - Country:US
Mailing Address - Phone:612-806-1132
Mailing Address - Fax:
Practice Address - Street 1:900 LONG LAKE RD STE 160
Practice Address - Street 2:
Practice Address - City:NEW BRIGHTON
Practice Address - State:MN
Practice Address - Zip Code:55112-6414
Practice Address - Country:US
Practice Address - Phone:612-706-9630
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-11
Last Update Date:2021-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN304983101YA0400X
MN2686101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty