Provider Demographics
NPI:1114065810
Name:VANERSTROM, SALLY RENEE (LICSW)
Entity Type:Individual
Prefix:MS
First Name:SALLY
Middle Name:RENEE
Last Name:VANERSTROM
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1919 UNIVERSITY AVE W STE 100
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55104-3479
Mailing Address - Country:US
Mailing Address - Phone:651-266-7900
Mailing Address - Fax:651-266-7855
Practice Address - Street 1:1919 UNIVERSITY AVE W STE 100
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55104-3479
Practice Address - Country:US
Practice Address - Phone:651-266-7900
Practice Address - Fax:651-266-7855
Is Sole Proprietor?:No
Enumeration Date:2007-02-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN162681041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical