Provider Demographics
NPI:1194897652
Name:ROSKE-GROTH, MARY LEE (LICSW, LADC)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:LEE
Last Name:ROSKE-GROTH
Suffix:
Gender:F
Credentials:LICSW, LADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:410 CHURCH ST SE
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55455-0340
Mailing Address - Country:US
Mailing Address - Phone:612-624-7172
Mailing Address - Fax:612-625-1434
Practice Address - Street 1:410 CHURCH ST SE
Practice Address - Street 2:BOYNTON HEALTH SERVICE
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55455-0340
Practice Address - Country:US
Practice Address - Phone:612-624-1444
Practice Address - Fax:612-625-7155
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-13
Last Update Date:2010-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN300299101YA0400X
MN149981041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)