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NPI Code Detail

MEDICARE: MS. NICKY DIANE BREDESON LICSW LMFT

MEDICARE: MS. NICKY DIANE BREDESON LICSW LMFT
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
11041C0700XClinical Social WorkerL.I.C.S.W. 257MN
2106H00000XMarriage & Family TherapistL.M.F.T.564MN

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
1LICSW257OTHERMNLICENSE NUMBER
2LMFT564OTHERMNLICENSE NUMBER

General Provider Information

NPI Number : 1487717344
Entity Type Code : Individual
Provider Name (Legal Business Name) : MS. NICKY DIANE BREDESON LICSW LMFT
Provider Business Mailing Address
First Line : 4005 WEST 65TH ST
Second Line : #108
City : EDINA
State : MN
Zip : 55435-1700
Country : US
Telephone Number : 952-929-1819
Fax Number : 952-929-0022
Provider Business Practice Location Address
First Line : 4005 WEST 65TH ST
Second Line : #108
City : EDINA
State : MN
Zip : 55435-1700
Country : US
Telephone Number : 952-929-1819
Fax Number : 952-929-0022
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 12/19/2006
Last Update Date : 09/11/2025

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