Provider Demographics
NPI:1346542727
Name:OWEN, BRENDA L (LAC, LICSW)
Entity Type:Individual
Prefix:
First Name:BRENDA
Middle Name:L
Last Name:OWEN
Suffix:
Gender:F
Credentials:LAC, LICSW
Other - Prefix:
Other - First Name:BRENDA
Other - Middle Name:L
Other - Last Name:OWEN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LAC, LICSW
Mailing Address - Street 1:1500 14TH ST W STE 290
Mailing Address - Street 2:
Mailing Address - City:WILLISTON
Mailing Address - State:ND
Mailing Address - Zip Code:58801-4078
Mailing Address - Country:US
Mailing Address - Phone:701-334-6242
Mailing Address - Fax:701-713-3299
Practice Address - Street 1:1500 14TH ST W STE 290
Practice Address - Street 2:
Practice Address - City:WILLISTON
Practice Address - State:ND
Practice Address - Zip Code:58801-4078
Practice Address - Country:US
Practice Address - Phone:701-334-6242
Practice Address - Fax:701-713-3299
Is Sole Proprietor?:Yes
Enumeration Date:2010-11-17
Last Update Date:2018-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND1613101YA0400X
ND47551041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND1454696Medicaid