Provider Demographics
NPI:1750018644
Name:DIETRICH, GRANT (LPCC, LADC)
Entity type:Individual
Prefix:
First Name:GRANT
Middle Name:
Last Name:DIETRICH
Suffix:
Gender:M
Credentials:LPCC, LADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3189 COUNTRYSIDE AVE UNIT F
Mailing Address - Street 2:
Mailing Address - City:WOODBURY
Mailing Address - State:MN
Mailing Address - Zip Code:55129-7837
Mailing Address - Country:US
Mailing Address - Phone:651-746-9131
Mailing Address - Fax:
Practice Address - Street 1:6040 EARLE BROWN DR STE 100
Practice Address - Street 2:
Practice Address - City:BROOKLYN CENTER
Practice Address - State:MN
Practice Address - Zip Code:55430-2561
Practice Address - Country:US
Practice Address - Phone:651-313-8080
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-08-02
Last Update Date:2022-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNCC00991101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health