Basic Information
| Provider Information | |||||||||
| NPI: | 1073716023 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DICK | ||||||||
| FirstName: | JOHN | ||||||||
| MiddleName: | D | ||||||||
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| Credential: | MSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 11307 TOWERING PINES CT | ||||||||
| Address2: | |||||||||
| City: | BEMIDJI | ||||||||
| State: | MN | ||||||||
| PostalCode: | 56601 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2186793912 | ||||||||
| FaxNumber: | 2186790181 | ||||||||
| Practice Location | |||||||||
| Address1: | HWY 1 | ||||||||
| Address2: | |||||||||
| City: | REDLAKE | ||||||||
| State: | MN | ||||||||
| PostalCode: | 566710497 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2186793912 | ||||||||
| FaxNumber: | 2186790181 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/07/2007 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | 3283 | MN | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
ID Information
| ID | Type | State | Issuer | Description | 3283 | 01 | MN | LICSW | OTHER |