Healthcare Provider Details

I. General information

NPI: 1659457596
Provider Name (Legal Business Name): MARTHA BEENKEN MSW., LICSW.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/31/2006
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4655 NICOLS RD SUITE 206
EAGAN MN
55122-2395
US

IV. Provider business mailing address

4655 NICOLS RD SUITE 206
EAGAN MN
55122-3425
US

V. Phone/Fax

Practice location:
  • Phone: 612-597-5986
  • Fax: 651-405-0358
Mailing address:
  • Phone: 612-597-5986
  • Fax: 651-405-0358

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number14040 LICSW
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: