Provider Demographics
NPI:1528155140
Name:SWANSON, RANDY JUDD (LICSW)
Entity type:Individual
Prefix:
First Name:RANDY
Middle Name:JUDD
Last Name:SWANSON
Suffix:
Gender:M
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6040 EARLE BROWN DR
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN CENTER
Mailing Address - State:MN
Mailing Address - Zip Code:55430-2514
Mailing Address - Country:US
Mailing Address - Phone:763-213-7405
Mailing Address - Fax:612-879-5272
Practice Address - Street 1:6040 EARLE BROWN DR
Practice Address - Street 2:
Practice Address - City:BROOKLYN CENTER
Practice Address - State:MN
Practice Address - Zip Code:55430-2514
Practice Address - Country:US
Practice Address - Phone:952-666-5896
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-06
Last Update Date:2017-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN27581041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN950557100Medicaid