Provider Demographics
NPI:1871089482
Name:MCGIBBON, BRENDEN (LICSW)
Entity type:Individual
Prefix:
First Name:BRENDEN
Middle Name:
Last Name:MCGIBBON
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 1:2120 PARK AVE
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55404-3378
Mailing Address - Country:US
Mailing Address - Phone:612-872-2000
Mailing Address - Fax:
Practice Address - Street 1:2120 PARK AVE
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55404-3378
Practice Address - Country:US
Practice Address - Phone:612-872-2000
Practice Address - Fax:612-871-1375
Is Sole Proprietor?:No
Enumeration Date:2018-07-06
Last Update Date:2019-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN243091041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN1871089482Medicaid