Provider Demographics
NPI:1598709628
Name:OMORI, GREG L (LICSW)
Entity Type:Individual
Prefix:
First Name:GREG
Middle Name:L
Last Name:OMORI
Suffix:
Gender:M
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2925 CHICAGO AVE
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55407-1321
Mailing Address - Country:US
Mailing Address - Phone:612-262-4813
Mailing Address - Fax:612-262-4194
Practice Address - Street 1:1217 8TH ST N
Practice Address - Street 2:
Practice Address - City:NEW ULM
Practice Address - State:MN
Practice Address - Zip Code:56073-1552
Practice Address - Country:US
Practice Address - Phone:507-233-1000
Practice Address - Fax:507-233-1327
Is Sole Proprietor?:No
Enumeration Date:2006-06-16
Last Update Date:2018-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN18251041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical