Healthcare Provider Details

I. General information

NPI: 1871285585
Provider Name (Legal Business Name): LAUREN GRACE IVESTER TETRAULT MSW, LICSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: LAUREN IVESTER

II. Dates (important events)

Enumeration Date: 05/22/2023
Last Update Date: 09/07/2026
Certification Date: 09/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

310 CLIFTON AVE
MINNEAPOLIS MN
55403-3218
US

IV. Provider business mailing address

310 CLIFTON AVE
MINNEAPOLIS MN
55403-3218
US

V. Phone/Fax

Practice location:
  • Phone: 612-223-8898
  • Fax:
Mailing address:
  • Phone: 612-223-8898
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number33540
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: