Provider Demographics
NPI:1841160470
Name:LIVERMORE, GRACE PHYLLIS (LICSW)
Entity type:Individual
Prefix:
First Name:GRACE
Middle Name:PHYLLIS
Last Name:LIVERMORE
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 1:3033 EXCELSIOR BLVD STE 10
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55416-5147
Mailing Address - Country:US
Mailing Address - Phone:844-324-7820
Mailing Address - Fax:
Practice Address - Street 1:3033 EXCELSIOR BLVD STE 10
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55416-5147
Practice Address - Country:US
Practice Address - Phone:844-324-7820
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-11-08
Last Update Date:2025-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN325431041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical