Healthcare Provider Details

I. General information

NPI: 1245554161
Provider Name (Legal Business Name): MARY ELLEN BIGHAM MSW, LICSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/22/2010
Last Update Date: 10/27/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13603 80TH CIRCLE NORTH
MAPLE GROVE MN
55369
US

IV. Provider business mailing address

1900 SILVER LAKE RD NW SUITE 110
NEW BRIGHTON MN
55112-1786
US

V. Phone/Fax

Practice location:
  • Phone: 763-416-1489
  • Fax: 763-416-3957
Mailing address:
  • Phone: 651-379-1764
  • Fax: 651-379-1738

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: