MEDICARE: EAST METRO TRAUMA AND RECOVERY LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QM0801X	Mental Health Clinic/Center (Including Community Mental Health Center)

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	2672	OTHER	MN	BOARD OF MARRIAGE AND FAMILY THERAPY LICENSING BOARD

General Provider Information

NPI Number	:	1740880764
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EAST METRO TRAUMA AND RECOVERY LLC

Provider Business Mailing Address
First Line	:	8154 ENCLAVE RD
Second Line	:
City	:	WOODBURY
State	:	MN
Zip	:	55125-3032
Country	:	US
Telephone Number	:	612-590-4440
Fax Number	:	651-494-5915

Provider Business Practice Location Address
First Line	:	4116 HOFFMAN RD
Second Line	:
City	:	WHITE BEAR LAKE
State	:	MN
Zip	:	55110-3708
Country	:	US
Telephone Number	:	612-590-4440
Fax Number	:	651-494-5915

Authorized Official
Title or Position	:	OWNER/CEO
Name	:	PAMELA LYNN GRABER
Credential	:	LMFT
Telephone Number	:	612-590-4440

Provider Enumeration Date	:	10/28/2020
Last Update Date	:	07/21/2022

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