Healthcare Provider Details

I. General information

NPI: 1720674799
Provider Name (Legal Business Name): SARA LEAHY LICSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/14/2020
Last Update Date: 12/30/2020
Certification Date: 12/30/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

640 JACKSON ST # MC11106G
SAINT PAUL MN
55101-2502
US

IV. Provider business mailing address

8170 33RD AVE S MS 21110Q
BLOOMINGTON MN
55425-4516
US

V. Phone/Fax

Practice location:
  • Phone: 651-254-2256
  • Fax: 651-254-2801
Mailing address:
  • Phone: 651-254-4816
  • Fax: 651-254-2801

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number24433
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: