Healthcare Provider Details

I. General information

NPI: 1790254209
Provider Name (Legal Business Name): ANDREA ELIZABETH NORTHRUP MS, LPCC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/14/2018
Last Update Date: 11/14/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7945 STONE CREEK DR STE 140
CHANHASSEN MN
55317-4606
US

IV. Provider business mailing address

7945 STONE CREEK DR STE 140
CHANHASSEN MN
55317-4606
US

V. Phone/Fax

Practice location:
  • Phone: 952-974-3999
  • Fax: 952-974-3780
Mailing address:
  • Phone: 952-974-3999
  • Fax: 952-974-3780

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberCC01641
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: