Healthcare Provider Details

I. General information

NPI: 1821566498
Provider Name (Legal Business Name): JEANNE MARTHA ABICHT MSW LICSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/12/2018
Last Update Date: 05/02/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12918 63RD AVE N
MAPLE GROVE MN
55369-6001
US

IV. Provider business mailing address

12918 63RD AVE N
MAPLE GROVE MN
55369-6001
US

V. Phone/Fax

Practice location:
  • Phone: 763-219-9966
  • Fax:
Mailing address:
  • Phone: 763-210-9966
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number23823
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: