Basic Information
| Provider Information | |||||||||
| NPI: | 1407012685 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GROSSMANN BROWN | ||||||||
| FirstName: | LESLIE | ||||||||
| MiddleName: | ANNE | ||||||||
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| Credential: | LCSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1821 UNIVERSITY AVE WEST SUITE N 385 | ||||||||
| Address2: | AVALON ST. ANTHONY PARK MERIDIAN BEHAVIORAL HEALTH | ||||||||
| City: | SAINT PAUL | ||||||||
| State: | MN | ||||||||
| PostalCode: | 551042803 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6123267579 | ||||||||
| FaxNumber: | 8773671715 | ||||||||
| Practice Location | |||||||||
| Address1: | 1821 UNIVERSITY AVE W STE N385 | ||||||||
| Address2: | |||||||||
| City: | SAINT PAUL | ||||||||
| State: | MN | ||||||||
| PostalCode: | 55104 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6516470095 | ||||||||
| FaxNumber: | 6516479147 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/06/2008 | ||||||||
| LastUpdateDate: | 08/22/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 24430 | MN | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 1952766651 | 05 | MN | MEDICAID | 140712685 | 05 | MN | MEDICAID | 205557491 | 05 | MN | MEDICAID |