Provider Demographics
NPI:1699984211
Name:GROSKLAGS, KELLY E (LICSW)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:E
Last Name:GROSKLAGS
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:621 W LAKE ST
Mailing Address - Street 2:SUITE 209
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55408-2949
Mailing Address - Country:US
Mailing Address - Phone:612-825-7400
Mailing Address - Fax:
Practice Address - Street 1:621 W LAKE ST
Practice Address - Street 2:SUITE 209
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55408-2949
Practice Address - Country:US
Practice Address - Phone:612-825-7400
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLICSW 99271041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN3076650OtherHEALTH PARTNERS
MN6290368OtherMEDICA
MN318M3GROtherBCBS