1245019330 NPI number — LAURA MICHELLE GROENEWEG MSW, LICSW

Table of content: LAURA MICHELLE GROENEWEG MSW, LICSW (NPI 1245019330)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1245019330 NPI number — LAURA MICHELLE GROENEWEG MSW, LICSW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GROENEWEG
Provider First Name:
LAURA
Provider Middle Name:
MICHELLE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MSW, LICSW
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:
1245019330
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/03/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
310 4TH AVE S STE 5010
Provider Second Line Business Mailing Address:
PMB 92494
Provider Business Mailing Address City Name:
MINNEAPOLIS
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55415-3143
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
612-208-9675
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3033 CAMPUS DR STE E180
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PLYMOUTH
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55441-2743
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
524-609-0869
Provider Business Practice Location Address Fax Number:
763-416-0916
Provider Enumeration Date:
09/27/2023

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: 1041C0700X , with the licence number:  18133 , 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)