1194897652 NPI number — MARY LEE ROSKE-GROTH LICSW, LADC

Table of content: MARY LEE ROSKE-GROTH LICSW, LADC (NPI 1194897652)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1194897652 NPI number — MARY LEE ROSKE-GROTH LICSW, LADC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ROSKE-GROTH
Provider First Name:
MARY
Provider Middle Name:
LEE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
LICSW, LADC
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1194897652
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/25/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
410 CHURCH ST SE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MINNEAPOLIS
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55455-0340
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
612-624-7172
Provider Business Mailing Address Fax Number:
612-625-1434

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
410 CHURCH ST SE
Provider Second Line Business Practice Location Address:
BOYNTON HEALTH SERVICE
Provider Business Practice Location Address City Name:
MINNEAPOLIS
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55455-0340
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
612-624-1444
Provider Business Practice Location Address Fax Number:
612-625-7155
Provider Enumeration Date:
11/13/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 101YA0400X , with the licence number:  300299 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 1041C0700X , with the licence number: 14998 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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