Provider Demographics
NPI:1629102629
Name:IPSEN, CHARLOTTE JEAN (MSW, LICSW)
Entity Type:Individual
Prefix:
First Name:CHARLOTTE
Middle Name:JEAN
Last Name:IPSEN
Suffix:
Gender:F
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 1:2406 GLENWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55405-1013
Mailing Address - Country:US
Mailing Address - Phone:612-377-1701
Mailing Address - Fax:
Practice Address - Street 1:2406 GLENWOOD AVE
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55405-1013
Practice Address - Country:US
Practice Address - Phone:612-377-1701
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLICSW 20751041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN6G082IPOtherBLUE CROSS BLUE SHIELD
MN62-91630OtherUHC MEDICA