Provider Demographics
NPI:1366950081
Name:ANTONSON, SARA MARIE (LMFT)
Entity type:Individual
Prefix:MS
First Name:SARA
Middle Name:MARIE
Last Name:ANTONSON
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7610 PENN AVE S APT 251
Mailing Address - Street 2:
Mailing Address - City:RICHFIELD
Mailing Address - State:MN
Mailing Address - Zip Code:55423-3681
Mailing Address - Country:US
Mailing Address - Phone:952-393-8047
Mailing Address - Fax:
Practice Address - Street 1:1100 GLENWOOD AVE
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55405-1430
Practice Address - Country:US
Practice Address - Phone:952-975-8264
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-01-16
Last Update Date:2018-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALF60686286106H00000X
MN3627106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist