Provider Demographics
NPI:1598950792
Name:SJOSTROM, DAVID BRUCE (BA, LADC)
Entity Type:Individual
Prefix:MR
First Name:DAVID
Middle Name:BRUCE
Last Name:SJOSTROM
Suffix:
Gender:M
Credentials:BA, LADC
Other - Prefix:
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Mailing Address - Street 1:1510 BEMIDJI AVE N STE 13
Mailing Address - Street 2:
Mailing Address - City:BEMIDJI
Mailing Address - State:MN
Mailing Address - Zip Code:56601-3804
Mailing Address - Country:US
Mailing Address - Phone:218-444-5740
Mailing Address - Fax:218-333-0241
Practice Address - Street 1:1510 BEMIDJI AVE N
Practice Address - Street 2:STE 13
Practice Address - City:BEMIDJI
Practice Address - State:MN
Practice Address - Zip Code:56601-3800
Practice Address - Country:US
Practice Address - Phone:218-444-5740
Practice Address - Fax:218-333-0241
Is Sole Proprietor?:No
Enumeration Date:2007-09-11
Last Update Date:2007-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN301521101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)