Provider Demographics
NPI:1629811955
Name:THELEN, ADDISON R (LICSW)
Entity type:Individual
Prefix:
First Name:ADDISON
Middle Name:R
Last Name:THELEN
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:ADDIE
Other - Middle Name:
Other - Last Name:THELEN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LICSW
Mailing Address - Street 1:4850 CARLETON RD
Mailing Address - Street 2:
Mailing Address - City:MINNETONKA
Mailing Address - State:MN
Mailing Address - Zip Code:55343-8732
Mailing Address - Country:US
Mailing Address - Phone:952-250-1754
Mailing Address - Fax:
Practice Address - Street 1:9120 SPRINGBROOK DR NW
Practice Address - Street 2:
Practice Address - City:COON RAPIDS
Practice Address - State:MN
Practice Address - Zip Code:55433-5845
Practice Address - Country:US
Practice Address - Phone:612-400-6120
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-06-14
Last Update Date:2024-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN293791041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical