Provider Demographics
NPI:1053974865
Name:SWANSON, JUSTIN W (LICSW)
Entity type:Individual
Prefix:
First Name:JUSTIN
Middle Name:W
Last Name:SWANSON
Suffix:
Gender:M
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4720 GRAND AVE S UNIT 2
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55419-5430
Mailing Address - Country:US
Mailing Address - Phone:612-227-9014
Mailing Address - Fax:651-455-1385
Practice Address - Street 1:750 S PLAZA DR STE 100
Practice Address - Street 2:
Practice Address - City:MENDOTA HEIGHTS
Practice Address - State:MN
Practice Address - Zip Code:55120-1505
Practice Address - Country:US
Practice Address - Phone:612-227-9014
Practice Address - Fax:651-455-1385
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-17
Last Update Date:2019-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN222711041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical