Provider Demographics
NPI:1730559584
Name:JOEL GROSTEPHAN, LICSW, LLC
Entity type:Organization
Organization Name:JOEL GROSTEPHAN, LICSW, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:THERAPIST/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JOEL
Authorized Official - Middle Name:PAUL
Authorized Official - Last Name:GROSTEPHAN
Authorized Official - Suffix:
Authorized Official - Credentials:LICSW
Authorized Official - Phone:612-839-5853
Mailing Address - Street 1:3011 36TH AVE. S., #10
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55406
Mailing Address - Country:US
Mailing Address - Phone:612-839-5853
Mailing Address - Fax:
Practice Address - Street 1:3011 36TH AVE S STE 10
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55406-2800
Practice Address - Country:US
Practice Address - Phone:612-839-5853
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-10-05
Last Update Date:2015-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN20930251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health