Basic Information
| Provider Information | |||||||||
| NPI: | 1609133297 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BROSTAD | ||||||||
| FirstName: | GREG | ||||||||
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| Credential: | LPC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 5045 | ||||||||
| Address2: | ATTN: P.F.S. PROV ENROLLMT | ||||||||
| City: | SIOUX FALLS | ||||||||
| State: | SD | ||||||||
| PostalCode: | 571175045 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6053226428 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 2412 S CLIFF AVE | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | SIOUX FALLS | ||||||||
| State: | SD | ||||||||
| PostalCode: | 571054031 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6053224079 | ||||||||
| FaxNumber: | 6053224080 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/19/2012 | ||||||||
| LastUpdateDate: | 04/19/2012 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YP2500X | 7152 | SD | Y | Behavioral Health & Social Service Providers | Counselor | Professional |
No ID Information.