Healthcare Provider Details

I. General information

NPI: 1679417695
Provider Name (Legal Business Name): AMY MELISSA HABEDANK LICSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/18/2026
Last Update Date: 04/24/2026
Certification Date: 04/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1068 LAKE ST S STE 109
FOREST LAKE MN
55025-2633
US

IV. Provider business mailing address

8972 BATAAN CT
MINNEAPOLIS MN
55449-5649
US

V. Phone/Fax

Practice location:
  • Phone: 651-982-4792
  • Fax: 651-982-6035
Mailing address:
  • Phone: 507-301-3412
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number11936
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: