Provider Demographics
NPI:1942246806
Name:GREDVIG, VIAN MAUREEN (MSW, LICSW)
Entity Type:Individual
Prefix:
First Name:VIAN
Middle Name:MAUREEN
Last Name:GREDVIG
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 1:10217 CRESTRIDGE DR
Mailing Address - Street 2:
Mailing Address - City:HOPKINS
Mailing Address - State:MN
Mailing Address - Zip Code:55305-1605
Mailing Address - Country:US
Mailing Address - Phone:952-412-4490
Mailing Address - Fax:952-224-4862
Practice Address - Street 1:1001 TWELVE OAKS CENTER DR STE 1030D
Practice Address - Street 2:
Practice Address - City:WAYZATA
Practice Address - State:MN
Practice Address - Zip Code:55391-4320
Practice Address - Country:US
Practice Address - Phone:952-224-4862
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-21
Last Update Date:2023-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1041C0700X
MN65771041C0700X
MN065771041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNH100234918Medicaid
H400234929OtherMEDICARE PTAN
MN1942246806Medicaid
MN1942683669Medicaid