Provider Demographics
NPI:1366041683
Name:ELLINGSON, BRYAN (MSW, LICSW)
Entity Type:Individual
Prefix:
First Name:BRYAN
Middle Name:
Last Name:ELLINGSON
Suffix:
Gender:M
Credentials:MSW, LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1821 UNIVERSITY AVE W # 306A
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55104-2801
Mailing Address - Country:US
Mailing Address - Phone:612-568-8670
Mailing Address - Fax:
Practice Address - Street 1:1821 UNIVERSITY AVE W # 306A
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55104-2801
Practice Address - Country:US
Practice Address - Phone:612-568-8670
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-19
Last Update Date:2020-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN265051041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical