Provider Demographics
NPI:1649865270
Name:HEDSTROM, ERIN NICHOLE (LADC)
Entity type:Individual
Prefix:
First Name:ERIN
Middle Name:NICHOLE
Last Name:HEDSTROM
Suffix:
Gender:F
Credentials:LADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8761 INVERNESS RD
Mailing Address - Street 2:
Mailing Address - City:WOODBURY
Mailing Address - State:MN
Mailing Address - Zip Code:55125-9393
Mailing Address - Country:US
Mailing Address - Phone:651-373-3744
Mailing Address - Fax:
Practice Address - Street 1:444 12TH AVE N
Practice Address - Street 2:
Practice Address - City:SOUTH ST PAUL
Practice Address - State:MN
Practice Address - Zip Code:55075-1914
Practice Address - Country:US
Practice Address - Phone:651-917-6248
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-05
Last Update Date:2021-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN305660101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)