Shawn Rae Disterhaupt

Primary specialty

Clinical Social WorkerTaxonomy code 1041C0700X

License

26111 Issued in MN

Practice address

606 Front St
Brainerd, MN 56401-3602

Phone

(218) 232-6247

NPI assigned

Apr 12, 2023

Sex

Male

Sole proprietor

No

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 1

Addresses

Medicare fee-for-service enrollment

Enrolled in MN

Eligible to order & refer

• Part B services: Yes
• Medical equipment: Yes
• Home health: No
• Power mobility devices: No
• Hospice: No

Green means eligible to order or refer.

Enrollment records 1

Medicare enrollment (NPD)

Enrolled

Practice roles

Locations

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships and National Provider Directory roles.

• Northern Pines Mental Health Center, Inc.

  • Mental Health Clinic/Center (Including Community Mental Health Center)
  • Little Falls, MN
  • NPI 1013904051
  Medicare reassignment NPD
• Northern Pines Mental Health Center, Inc.

  • Community/Behavioral Health Agency
  • Brainerd, MN
  • NPI 1225168602
  NPD (past)

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1681257600000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1681257600000",
    "number": "1942996087",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "203 H ST NE",
            "city": "BRAINERD",
            "state": "MN",
            "postal_code": "564012404"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "606 FRONT ST",
            "city": "BRAINERD",
            "state": "MN",
            "postal_code": "564013602",
            "telephone_number": "218-232-6247"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "DISTERHAUPT",
        "first_name": "SHAWN",
        "middle_name": "RAE",
        "sole_proprietor": "NO",
        "sex": "M",
        "enumeration_date": "2023-04-12",
        "last_updated": "2023-04-12",
        "certification_date": "2023-04-12",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "1041C0700X",
            "taxonomy_group": "",
            "desc": "Social Worker, Clinical",
            "state": "MN",
            "license": "26111",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

• Vishnuteja V Devalla, M.D.
• Diagnostic Imaging Specialists, P.a.
• Danette Lee Diethert, PMHNP
• Discovery Woods Montessori
• Catherine Disterhaupt, LPCC
• Marci Marie Douts, LPCC
• Samuel Duberowski, DDS
• Susan K Dudding, CNP
• Troy M Duininck, MD
• Karli G Dullum, APRN, CNP

• Clinical Social Worker in Brainerd, MN
• Providers in Brainerd, MN by specialty
• Clinical Social Worker in Minnesota

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Apr 12, 2023; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; Order and Referring.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.