Basic Information
| Provider Information | |||||||||
| NPI: | 1679639777 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HEDIN | ||||||||
| FirstName: | NANCY | ||||||||
| MiddleName: | JEAN | ||||||||
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| Credential: | LICSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1711 VAN BUREN AVE | ||||||||
| Address2: | |||||||||
| City: | SAINT PAUL | ||||||||
| State: | MN | ||||||||
| PostalCode: | 551041730 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6516467062 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1919 UNIVERSITY AVE W STE 200 | ||||||||
| Address2: | |||||||||
| City: | SAINT PAUL | ||||||||
| State: | MN | ||||||||
| PostalCode: | 551043435 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6512667900 | ||||||||
| FaxNumber: | 6512667850 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/31/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 06866 | MN | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 291558800 | 05 | MN | MEDICAID |