Basic Information
| Provider Information | |||||||||
| NPI: | 1386060465 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DAHLSTROM | ||||||||
| FirstName: | LAURA | ||||||||
| MiddleName: | JANE | ||||||||
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| Credential: | LPCC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3450 OLEARY LN | ||||||||
| Address2: | |||||||||
| City: | EAGAN | ||||||||
| State: | MN | ||||||||
| PostalCode: | 551232340 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6513658230 | ||||||||
| FaxNumber: | 6514543492 | ||||||||
| Practice Location | |||||||||
| Address1: | 3450 OLEARY LN | ||||||||
| Address2: | |||||||||
| City: | EAGAN | ||||||||
| State: | MN | ||||||||
| PostalCode: | 551232340 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6513658230 | ||||||||
| FaxNumber: | 6514543492 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/12/2014 | ||||||||
| LastUpdateDate: | 03/12/2014 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101Y00000X | CC00735 | MN | N | Behavioral Health & Social Service Providers | Counselor | 101YM0800X | CC00735 | MN | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.