Healthcare Provider Details

I. General information

NPI: 1154087278
Provider Name (Legal Business Name): LAURA LYMAN LICSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/12/2021
Last Update Date: 11/12/2021
Certification Date: 11/10/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2700 SNELLING AVE N STE 400
ROSEVILLE MN
55113-1783
US

IV. Provider business mailing address

8788 ACADIA RD
WOODBURY MN
55125-3479
US

V. Phone/Fax

Practice location:
  • Phone: 763-525-9919
  • Fax: 763-486-4436
Mailing address:
  • Phone: 936-355-0928
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number23349
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: