Basic Information
| Provider Information | |||||||||
| NPI: | 1437197084 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KUNTZ | ||||||||
| FirstName: | DAWN | ||||||||
| MiddleName: | M. | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | LICSW | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | JOHNSON | ||||||||
| OtherFirstName: | DAWN | ||||||||
| OtherMiddleName: | M. | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | LICSW | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1619 37TH AVE S | ||||||||
| Address2: | |||||||||
| City: | FARGO | ||||||||
| State: | ND | ||||||||
| PostalCode: | 581046331 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7012394471 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 2405 8TH ST S STE 200 | ||||||||
| Address2: | |||||||||
| City: | MOORHEAD | ||||||||
| State: | MN | ||||||||
| PostalCode: | 565604224 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2183314866 | ||||||||
| FaxNumber: | 2183314867 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/04/2006 | ||||||||
| LastUpdateDate: | 05/14/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 05/14/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 11211 | MN | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | P00261628 | 01 | MN | RAILROAD MEDICARE | OTHER | 1031163 | 01 | MN | PREFERREDONE | OTHER | HP35763 | 01 | MN | HEALTHPARTNERS | OTHER | 23334 | 01 | ND | NORRTH DAKOTA BLUE SHIELD | OTHER | 142522 | 01 | MN | UCARE MINNESOTA | OTHER | 155532400 | 05 | MN | MEDICAID | 338S0KU | 01 | MN | BLUE SHIELD OF MINNESOTA | OTHER | 62-71654 | 01 | MN | UNITED BEHAVIORAL HEALTH | OTHER |