Provider Demographics
NPI:1134229990
Name:BRADY, ELIZABETH HUBBARD (LICSW)
Entity type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:HUBBARD
Last Name:BRADY
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 1:1619 DAYTON AVE
Mailing Address - Street 2:SUITE 110
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55104-6206
Mailing Address - Country:US
Mailing Address - Phone:651-523-8800
Mailing Address - Fax:651-523-8811
Practice Address - Street 1:1619 DAYTON AVE
Practice Address - Street 2:SUITE 110
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55104-6206
Practice Address - Country:US
Practice Address - Phone:651-523-8800
Practice Address - Fax:651-523-8811
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-22
Last Update Date:2008-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN097971041C0700X, 104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN55G76BROtherBLUE CROSS/BLUE SHIELD