Provider Demographics
NPI:1710108790
Name:HANENBURG, JULIE ANN (LICSW)
Entity Type:Individual
Prefix:
First Name:JULIE
Middle Name:ANN
Last Name:HANENBURG
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:JULIE
Other - Middle Name:ANN
Other - Last Name:NYBAKKE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:150 10TH ST NW STE 2
Mailing Address - Street 2:
Mailing Address - City:MILACA
Mailing Address - State:MN
Mailing Address - Zip Code:56353-1737
Mailing Address - Country:US
Mailing Address - Phone:320-983-2335
Mailing Address - Fax:320-983-2330
Practice Address - Street 1:150 10TH ST NW STE 2
Practice Address - Street 2:
Practice Address - City:MILACA
Practice Address - State:MN
Practice Address - Zip Code:56353-1737
Practice Address - Country:US
Practice Address - Phone:320-983-2335
Practice Address - Fax:651-342-8029
Is Sole Proprietor?:No
Enumeration Date:2007-05-01
Last Update Date:2024-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN156031041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN632410000OtherMHCP PROVIDER NUMBER