1134146749 NPI number — SARAH JANE GROSS MSW, LICSW

Table of content: SARAH JANE GROSS MSW, LICSW (NPI 1134146749)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1134146749 NPI number — SARAH JANE GROSS MSW, LICSW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GROSS
Provider First Name:
SARAH
Provider Middle Name:
JANE
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:
MCKENDALL
Provider Other First Name:
SARAH
Provider Other Middle Name:
JANE
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1134146749
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/12/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1900 SILVER LAKE RD
Provider Second Line Business Mailing Address:
SUITE 110 NYSTROM & ASSOCIATES, LTD.
Provider Business Mailing Address City Name:
NEW BRIGHTON
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55112
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
651-628-9566
Provider Business Mailing Address Fax Number:
651-628-0411

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1900 SILVER LAKE RD #110
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
NEW BRIGHTON
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55112
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
651-628-9566
Provider Business Practice Location Address Fax Number:
651-628-0411
Provider Enumeration Date:
07/17/2006

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: 1041C0700X , with the licence number:  14423 , 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)

  • Identifier: 458969600 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".




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