=====================================================
General NPI Number Information
=====================================================
NPI Number | 1053511501
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SARAH HEATHER RAY O'REILLY LGSW
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/23/2007
-----------------------------------------------------
Last Update Date | 02/04/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4801 VETERANS DR BUILDING 28, ROOM 142A
-----------------------------------------------------
City | SAINT CLOUD
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 56303-2015
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 320-252-1670
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 913 6TH AVE NE APARTMENT 110
-----------------------------------------------------
City | BUFFALO
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55313-1864
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 320-252-1670
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 104100000X
-----------------------------------------------------
Taxonomy Name | Social Worker
-----------------------------------------------------
License Number | 18551
-----------------------------------------------------
License Number State | MN
-----------------------------------------------------