Provider Demographics
NPI:1942855408
Name:GROTEBOER-DISTAD, EMILY ANN (MS, LPCC, NCC)
Entity Type:Individual
Prefix:
First Name:EMILY
Middle Name:ANN
Last Name:GROTEBOER-DISTAD
Suffix:
Gender:F
Credentials:MS, LPCC, NCC
Other - Prefix:
Other - First Name:EMILY
Other - Middle Name:ANN
Other - Last Name:GROTEBOER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 51
Mailing Address - Street 2:
Mailing Address - City:VICTORIA
Mailing Address - State:MN
Mailing Address - Zip Code:55386-0051
Mailing Address - Country:US
Mailing Address - Phone:952-443-4600
Mailing Address - Fax:
Practice Address - Street 1:15265 CARROUSEL WAY STE 100
Practice Address - Street 2:
Practice Address - City:ROSEMOUNT
Practice Address - State:MN
Practice Address - Zip Code:55068-1760
Practice Address - Country:US
Practice Address - Phone:952-443-4600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-01
Last Update Date:2021-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
MNCC02555101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NAOtherNA