Provider Demographics
NPI:1740880764
Name:EAST METRO TRAUMA AND RECOVERY LLC
Entity type:Organization
Organization Name:EAST METRO TRAUMA AND RECOVERY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/CEO
Authorized Official - Prefix:
Authorized Official - First Name:PAMELA
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:GRABER
Authorized Official - Suffix:
Authorized Official - Credentials:LMFT
Authorized Official - Phone:612-590-4440
Mailing Address - Street 1:8154 ENCLAVE RD
Mailing Address - Street 2:
Mailing Address - City:WOODBURY
Mailing Address - State:MN
Mailing Address - Zip Code:55125-3032
Mailing Address - Country:US
Mailing Address - Phone:612-590-4440
Mailing Address - Fax:651-494-5915
Practice Address - Street 1:4116 HOFFMAN RD
Practice Address - Street 2:
Practice Address - City:WHITE BEAR LAKE
Practice Address - State:MN
Practice Address - Zip Code:55110-3708
Practice Address - Country:US
Practice Address - Phone:612-590-4440
Practice Address - Fax:651-494-5915
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-10-28
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN2672OtherBOARD OF MARRIAGE AND FAMILY THERAPY LICENSING BOARD