Healthcare Provider Details

I. General information

NPI: 1053567560
Provider Name (Legal Business Name): LEANNE MAIRS LICSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/15/2008
Last Update Date: 09/07/2026
Certification Date: 09/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1030 COUNTY ROAD E W
SHOREVIEW MN
55126-8152
US

IV. Provider business mailing address

PO BOX 270773
VADNAIS HEIGHTS MN
55127-0773
US

V. Phone/Fax

Practice location:
  • Phone: 651-249-1750
  • Fax:
Mailing address:
  • Phone: 651-249-1750
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number16359
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: