Provider Demographics
NPI:1295045649
Name:REARDON, SANDRA HAUKOM (LICSW)
Entity Type:Individual
Prefix:
First Name:SANDRA
Middle Name:HAUKOM
Last Name:REARDON
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 1:1609 W 31ST ST
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55408-2504
Mailing Address - Country:US
Mailing Address - Phone:612-518-3525
Mailing Address - Fax:
Practice Address - Street 1:1609 W 31ST ST
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55408-2504
Practice Address - Country:US
Practice Address - Phone:612-518-3525
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-10-19
Last Update Date:2020-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN175901041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical