Provider Demographics
NPI:1659928125
Name:POGUE, SARA NICOLE (LICSW)
Entity Type:Individual
Prefix:
First Name:SARA
Middle Name:NICOLE
Last Name:POGUE
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 1:3532 5TH AVE S
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55408-4531
Mailing Address - Country:US
Mailing Address - Phone:612-239-8811
Mailing Address - Fax:
Practice Address - Street 1:7580 160TH ST W
Practice Address - Street 2:
Practice Address - City:LAKEVILLE
Practice Address - State:MN
Practice Address - Zip Code:55044-8348
Practice Address - Country:US
Practice Address - Phone:952-898-1133
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-20
Last Update Date:2019-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN248851041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty