Provider Demographics
NPI:1952046294
Name:GROGAN PEDERSEN, GAIL JOHANNA (LICSW)
Entity Type:Individual
Prefix:
First Name:GAIL
Middle Name:JOHANNA
Last Name:GROGAN PEDERSEN
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 1:1355 SPENCER RD W
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55108-5206
Mailing Address - Country:US
Mailing Address - Phone:651-983-3743
Mailing Address - Fax:
Practice Address - Street 1:1355 SPENCER RD W
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55108-5206
Practice Address - Country:US
Practice Address - Phone:651-983-3743
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-05-02
Last Update Date:2022-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN136101041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical