Provider Demographics
NPI:1235452426
Name:BREEN, BETH ELLEN FEIKEMA (LICSW)
Entity Type:Individual
Prefix:
First Name:BETH
Middle Name:ELLEN FEIKEMA
Last Name:BREEN
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1068 LAKE ST S
Mailing Address - Street 2:#12
Mailing Address - City:FOREST LAKE
Mailing Address - State:MN
Mailing Address - Zip Code:55025-2639
Mailing Address - Country:US
Mailing Address - Phone:651-464-2194
Mailing Address - Fax:651-464-5744
Practice Address - Street 1:1345 SUMMIT AVE
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55105-2219
Practice Address - Country:US
Practice Address - Phone:651-464-2194
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-03-02
Last Update Date:2010-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN20631041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical