Healthcare Provider Details

I. General information

NPI: 1316759780
Provider Name (Legal Business Name): LINDSAY NICOLE HANENBURG LICSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: LINDSAY HAKES

II. Dates (important events)

Enumeration Date: 01/23/2025
Last Update Date: 01/23/2025
Certification Date: 01/23/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12555 UNIVERSITY AVE NE
MINNEAPOLIS MN
55434-2108
US

IV. Provider business mailing address

13631 186TH AVE NW
ELK RIVER MN
55330-1603
US

V. Phone/Fax

Practice location:
  • Phone: 763-506-6610
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number28200
License Number StateMN
# 2
Primary TaxonomyN
Taxonomy Code1041S0200X
TaxonomySchool Social Worker
License Number1006855
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: