MEDICARE: ABIGAIL BEASLEY LICSW

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker	19425	MN

General Provider Information

NPI Number	:	1316218118
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ABIGAIL BEASLEY LICSW

Provider Business Mailing Address
First Line	:	7600 BOONE AVE N
Second Line	:	SUITE 2
City	:	BROOKLYN PARK
State	:	MN
Zip	:	55428-4563
Country	:	US
Telephone Number	:	763-515-2441
Fax Number	:	763-515-2442

Provider Business Practice Location Address
First Line	:	4749 CHICAGO AVE STE 2D
Second Line	:
City	:	MINNEAPOLIS
State	:	MN
Zip	:	55407-4181
Country	:	US
Telephone Number	:	503-267-7292
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/25/2012
Last Update Date	:	12/03/2018

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