Provider Demographics
NPI:1083079693
Name:NELSON, SARA ANN (LICSW)
Entity Type:Individual
Prefix:
First Name:SARA
Middle Name:ANN
Last Name:NELSON
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:SARA
Other - Middle Name:
Other - Last Name:WALTONEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1674 JAMES AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55105-2111
Mailing Address - Country:US
Mailing Address - Phone:612-802-9564
Mailing Address - Fax:
Practice Address - Street 1:451 LEXINGTON PKWY N
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55104-4636
Practice Address - Country:US
Practice Address - Phone:651-280-2310
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-12-24
Last Update Date:2018-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN205251041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical