Provider Demographics
NPI:1962817718
Name:GREG E BROSTAD, LLC
Entity Type:Organization
Organization Name:GREG E BROSTAD, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:GREG
Authorized Official - Middle Name:E
Authorized Official - Last Name:BROSTAD
Authorized Official - Suffix:
Authorized Official - Credentials:LLC, QMHP, LAC
Authorized Official - Phone:605-322-4079
Mailing Address - Street 1:2412 S CLIFF AVE
Mailing Address - Street 2:
Mailing Address - City:SIOUX FALLS
Mailing Address - State:SD
Mailing Address - Zip Code:57105-4031
Mailing Address - Country:US
Mailing Address - Phone:605-322-4079
Mailing Address - Fax:605-335-0014
Practice Address - Street 1:2412 S CLIFF AVE
Practice Address - Street 2:
Practice Address - City:SIOUX FALLS
Practice Address - State:SD
Practice Address - Zip Code:57105-4031
Practice Address - Country:US
Practice Address - Phone:605-322-4079
Practice Address - Fax:605-335-0014
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-06-30
Last Update Date:2014-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health