Healthcare Provider Details

I. General information

NPI: 1427719467
Provider Name (Legal Business Name): ETHEN D SIETSEMA LPCC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/03/2022
Last Update Date: 04/18/2022
Certification Date: 04/18/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2925 CHICAGO AVE
MINNEAPOLIS MN
55407-1321
US

IV. Provider business mailing address

2925 CHICAGO AVE
MINNEAPOLIS MN
55407-1321
US

V. Phone/Fax

Practice location:
  • Phone: 866-603-0016
  • Fax:
Mailing address:
  • Phone: 612-262-9000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number3110
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: