Provider Demographics
NPI:1437633575
Name:ELKINGTON, BEAU JOHN (LICSW, LADC, MBA)
Entity Type:Individual
Prefix:
First Name:BEAU
Middle Name:JOHN
Last Name:ELKINGTON
Suffix:
Gender:M
Credentials:LICSW, LADC, MBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7590 LYRIC LN NE STE 114
Mailing Address - Street 2:
Mailing Address - City:FRIDLEY
Mailing Address - State:MN
Mailing Address - Zip Code:55432-3251
Mailing Address - Country:US
Mailing Address - Phone:763-236-4508
Mailing Address - Fax:
Practice Address - Street 1:7590 LYRIC LN NE STE 114
Practice Address - Street 2:
Practice Address - City:FRIDLEY
Practice Address - State:MN
Practice Address - Zip Code:55432-3251
Practice Address - Country:US
Practice Address - Phone:763-236-4373
Practice Address - Fax:763-236-4370
Is Sole Proprietor?:No
Enumeration Date:2018-09-24
Last Update Date:2018-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN304158101YA0400X
MN229161041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)