Provider Demographics
NPI:1790795797
Name:STENLUND, BRYAN JON (MS/LP)
Entity Type:Individual
Prefix:MR
First Name:BRYAN
Middle Name:JON
Last Name:STENLUND
Suffix:
Gender:M
Credentials:MS/LP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:516 S POKEGAMA AVE
Mailing Address - Street 2:STE B
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MN
Mailing Address - Zip Code:55744
Mailing Address - Country:US
Mailing Address - Phone:218-327-8937
Mailing Address - Fax:218-327-0348
Practice Address - Street 1:516 S POKEGAMA AVE
Practice Address - Street 2:STE B
Practice Address - City:GRAND RAPIDS
Practice Address - State:MN
Practice Address - Zip Code:55744
Practice Address - Country:US
Practice Address - Phone:218-327-8937
Practice Address - Fax:218-327-0348
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-09
Last Update Date:2016-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP2760103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN278247200Medicaid
MN278247200Medicaid