Basic Information
| Provider Information | |||||||||
| NPI: | 1417108770 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MCCLINTIC | ||||||||
| FirstName: | MICHELLE | ||||||||
| MiddleName: | C | ||||||||
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| Credential: | LCSW-PIP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 800 E 21ST ST | ||||||||
| Address2: | ATTN; P.F.S. | ||||||||
| City: | SIOUX FALLS | ||||||||
| State: | SD | ||||||||
| PostalCode: | 571051016 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6053226400 | ||||||||
| FaxNumber: | 6053226499 | ||||||||
| Practice Location | |||||||||
| Address1: | 2412 S CLIFF AVE | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | SIOUX FALLS | ||||||||
| State: | SD | ||||||||
| PostalCode: | 571054031 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6053224079 | ||||||||
| FaxNumber: | 6053224080 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/06/2008 | ||||||||
| LastUpdateDate: | 04/12/2010 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 2116 | SD | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 1417108770 | 01 | WELLMARK BCBS OF SD | OTHER | 1417108770 | 05 | MN | MEDICAID | 1417108770 | 01 | BCBS MN | OTHER | 9268404 | 01 | DAKOTACARE | OTHER |