Healthcare Provider Details

I. General information

NPI: 1639875156
Provider Name (Legal Business Name): ELISA FLYNN LICSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/06/2023
Last Update Date: 02/10/2025
Certification Date: 02/10/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2388 UNIVERSITY AVE W # 202
SAINT PAUL MN
55114-1769
US

IV. Provider business mailing address

5601 EMERSON AVE S
MINNEAPOLIS MN
55419-1622
US

V. Phone/Fax

Practice location:
  • Phone: 312-925-1541
  • Fax:
Mailing address:
  • Phone: 312-925-1541
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number28722
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: