Provider Demographics
NPI:1093277238
Name:HICKENBOTTOM, MEGAN (LICSW)
Entity type:Individual
Prefix:
First Name:MEGAN
Middle Name:
Last Name:HICKENBOTTOM
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:MEGAN
Other - Middle Name:
Other - Last Name:NESS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LICSW
Mailing Address - Street 1:3305 QUEENSLAND LN N
Mailing Address - Street 2:
Mailing Address - City:PLYMOUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55447-1133
Mailing Address - Country:US
Mailing Address - Phone:612-720-5632
Mailing Address - Fax:
Practice Address - Street 1:520 OSBORNE RD NE
Practice Address - Street 2:
Practice Address - City:FRIDLEY
Practice Address - State:MN
Practice Address - Zip Code:55432-2718
Practice Address - Country:US
Practice Address - Phone:763-236-7958
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-05
Last Update Date:2024-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN223691041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical