Healthcare Provider Details

I. General information

NPI: 1962312058
Provider Name (Legal Business Name): GRACE ELIZABETH CHANG LICSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/10/2026
Last Update Date: 09/10/2026
Certification Date: 09/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

813 S POKEGAMA AVE # 2
GRAND RAPIDS MN
55744-3934
US

IV. Provider business mailing address

2275 WALNUT GROVE LN N
PLYMOUTH MN
55447-2048
US

V. Phone/Fax

Practice location:
  • Phone: 651-272-2271
  • Fax:
Mailing address:
  • Phone: 763-234-9073
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number32381
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: