Provider Demographics
NPI:1134146749
Name:GROSS, SARAH JANE (MSW, LICSW)
Entity Type:Individual
Prefix:
First Name:SARAH
Middle Name:JANE
Last Name:GROSS
Suffix:
Gender:F
Credentials:MSW, LICSW
Other - Prefix:
Other - First Name:SARAH
Other - Middle Name:JANE
Other - Last Name:MCKENDALL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1900 SILVER LAKE RD
Mailing Address - Street 2:SUITE 110 NYSTROM & ASSOCIATES, LTD.
Mailing Address - City:NEW BRIGHTON
Mailing Address - State:MN
Mailing Address - Zip Code:55112
Mailing Address - Country:US
Mailing Address - Phone:651-628-9566
Mailing Address - Fax:651-628-0411
Practice Address - Street 1:1900 SILVER LAKE RD #110
Practice Address - Street 2:
Practice Address - City:NEW BRIGHTON
Practice Address - State:MN
Practice Address - Zip Code:55112
Practice Address - Country:US
Practice Address - Phone:651-628-9566
Practice Address - Fax:651-628-0411
Is Sole Proprietor?:No
Enumeration Date:2006-07-17
Last Update Date:2015-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN144231041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN458969600Medicaid
MN458969600Medicaid