MEDICARE: OSTARA INITIATIVE

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YM0800X	Mental Health Counselor
2	251S00000X	Community/Behavioral Health Agency

General Provider Information

NPI Number	:	1841957305
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	OSTARA INITIATIVE

Provider Business Mailing Address
First Line	:	PO BOX 18603
Second Line	:
City	:	MINNEAPOLIS
State	:	MN
Zip	:	55418-0603
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	5353 GAMBLE DR
Second Line	:
City	:	ST LOUIS PARK
State	:	MN
Zip	:	55416-1509
Country	:	US
Telephone Number	:	612-382-3095
Fax Number	:

Authorized Official
Title or Position	:	EXECUTIVE DIRECTOR
Name	:	MS. ERICA ELIZABETH GERRITY
Credential	:	LICSW
Telephone Number	:	612-382-3095

Provider Enumeration Date	:	11/19/2021
Last Update Date	:	11/19/2021

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Directions to “OSTARA INITIATIVE ” Practice Location

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