Provider Demographics
NPI:1922663236
Name:MAGNUSON, REBECCA ALLA ORRICK (LICSW)
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:ALLA ORRICK
Last Name:MAGNUSON
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2021 E HENNEPIN AVE STE 330
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55413-1798
Mailing Address - Country:US
Mailing Address - Phone:612-435-7234
Mailing Address - Fax:
Practice Address - Street 1:2021 E HENNEPIN AVE STE 330
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55413-1798
Practice Address - Country:US
Practice Address - Phone:612-435-7234
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-05-02
Last Update Date:2019-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLICSW1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical