Basic Information
| Provider Information | |||||||||
| NPI: | 1972504041 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LETIZIO | ||||||||
| FirstName: | SHARON | ||||||||
| MiddleName: | LISA | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MSW LICSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 540 E 1ST ST | ||||||||
| Address2: | |||||||||
| City: | WACONIA | ||||||||
| State: | MN | ||||||||
| PostalCode: | 553871601 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9524424437 | ||||||||
| FaxNumber: | 9524423084 | ||||||||
| Practice Location | |||||||||
| Address1: | 540 E 1ST ST | ||||||||
| Address2: | |||||||||
| City: | WACONIA | ||||||||
| State: | MN | ||||||||
| PostalCode: | 553871601 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9524424437 | ||||||||
| FaxNumber: | 9524423084 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/10/2005 | ||||||||
| LastUpdateDate: | 02/19/2014 | ||||||||
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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 | 104100000X | 09412 | MN | Y | Behavioral Health & Social Service Providers | Social Worker |
ID Information
| ID | Type | State | Issuer | Description | 6295013 | 01 | MN | UBH-MEDICA | OTHER | 802957100 | 05 | MN | MEDICAID | 88D04LE | 01 | MN | BCBS | OTHER | 1023604 | 01 | MN | PREFERRED ONE | OTHER | HP30776 | 01 | MN | HEALTH PARTNERS | OTHER |