Provider Demographics
NPI:1134968175
Name:ROE, ETHAN BJORN
Entity type:Individual
Prefix:
First Name:ETHAN
Middle Name:BJORN
Last Name:ROE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1840 MAJOR DR N
Mailing Address - Street 2:
Mailing Address - City:GOLDEN VALLEY
Mailing Address - State:MN
Mailing Address - Zip Code:55422-4153
Mailing Address - Country:US
Mailing Address - Phone:612-860-5737
Mailing Address - Fax:
Practice Address - Street 1:1900 SILVER LAKE RD NW STE 110
Practice Address - Street 2:
Practice Address - City:NEW BRIGHTON
Practice Address - State:MN
Practice Address - Zip Code:55112-1789
Practice Address - Country:US
Practice Address - Phone:651-419-4351
Practice Address - Fax:651-628-0411
Is Sole Proprietor?:No
Enumeration Date:2024-05-20
Last Update Date:2024-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor