Provider Demographics
NPI:1497812622
Name:SHARON GROSTEPHAN, LICSW
Entity Type:Organization
Organization Name:SHARON GROSTEPHAN, LICSW
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LICENSED SOCIAL WORKER
Authorized Official - Prefix:MS
Authorized Official - First Name:SHARON
Authorized Official - Middle Name:
Authorized Official - Last Name:GROSTEPHAN
Authorized Official - Suffix:
Authorized Official - Credentials:LICSW
Authorized Official - Phone:763-441-9712
Mailing Address - Street 1:1660 S HIGHWAY 100
Mailing Address - Street 2:SUITE 428
Mailing Address - City:ST LOUIS PARK
Mailing Address - State:MN
Mailing Address - Zip Code:55416-1533
Mailing Address - Country:US
Mailing Address - Phone:612-597-6585
Mailing Address - Fax:
Practice Address - Street 1:1660 S HIGHWAY 100
Practice Address - Street 2:SUITE 428
Practice Address - City:ST LOUIS PARK
Practice Address - State:MN
Practice Address - Zip Code:55416-1533
Practice Address - Country:US
Practice Address - Phone:612-597-6585
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-03
Last Update Date:2019-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLICSW 841104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes104100000XBehavioral Health & Social Service ProvidersSocial WorkerGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN834358600Medicaid