Provider Demographics
NPI:1487717344
Name:BREDESON, NICKY DIANE (LICSW LMFT)
Entity type:Individual
Prefix:MS
First Name:NICKY
Middle Name:DIANE
Last Name:BREDESON
Suffix:
Gender:F
Credentials:LICSW LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:4005 WEST 65TH ST
Mailing Address - Street 2:#108
Mailing Address - City:EDINA
Mailing Address - State:MN
Mailing Address - Zip Code:55435-1700
Mailing Address - Country:US
Mailing Address - Phone:952-929-1819
Mailing Address - Fax:952-929-0022
Practice Address - Street 1:4005 WEST 65TH ST
Practice Address - Street 2:#108
Practice Address - City:EDINA
Practice Address - State:MN
Practice Address - Zip Code:55435-1700
Practice Address - Country:US
Practice Address - Phone:952-929-1819
Practice Address - Fax:952-929-0022
Is Sole Proprietor?:No
Enumeration Date:2006-12-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNL.I.C.S.W. 2571041C0700X
MNL.M.F.T.564106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Not Answered106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNLICSW257OtherLICENSE NUMBER
MNLMFT564OtherLICENSE NUMBER