Healthcare Provider Details

I. General information

NPI: 1437695624
Provider Name (Legal Business Name): LAURA LINNER A.M., LICSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/11/2017
Last Update Date: 11/06/2020
Certification Date: 11/06/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5775 WAYZATA BLVD STE 255
ST LOUIS PARK MN
55416-1275
US

IV. Provider business mailing address

5775 WAYZATA BLVD STE 255
ST LOUIS PARK MN
55416-1275
US

V. Phone/Fax

Practice location:
  • Phone: 952-525-4500
  • Fax: 952-525-1560
Mailing address:
  • Phone: 952-525-4500
  • Fax: 952-525-1560

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number150102232
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number22298
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: