Basic Information
| Provider Information | |||||||||
| NPI: | 1629130075 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KNOFLICEK | ||||||||
| FirstName: | WILLIAM | ||||||||
| MiddleName: | J | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | PH.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | KNOFLICEK | ||||||||
| OtherFirstName: | WILLIAM | ||||||||
| OtherMiddleName: | J. | ||||||||
| OtherNamePrefix: | |||||||||
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| OtherCredential: | PH.D. | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 2400 S. MINNESOTA AVE | ||||||||
| Address2: | STE 100 | ||||||||
| City: | SIOUX FALLS | ||||||||
| State: | SD | ||||||||
| PostalCode: | 571053762 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6053227510 | ||||||||
| FaxNumber: | 6053226475 | ||||||||
| Practice Location | |||||||||
| Address1: | 4400 W 69TH ST | ||||||||
| Address2: | STE. 500 | ||||||||
| City: | SIOUX FALLS | ||||||||
| State: | SD | ||||||||
| PostalCode: | 571088171 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6053227580 | ||||||||
| FaxNumber: | 6053227579 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/14/2006 | ||||||||
| LastUpdateDate: | 02/18/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103T00000X | 461 | SD | Y | Behavioral Health & Social Service Providers | Psychologist |
ID Information
| ID | Type | State | Issuer | Description | 46022474326 | 05 | NE | MEDICAID | 4993504 | 01 | SD | WELLMARK BCBS | OTHER | 9236559 | 01 | SD | DAKOTACARE PROV # | OTHER | 247052700 | 05 | MN | MEDICAID | 6552352 | 05 | SD | MEDICAID | 99GO9KN | 01 | MN | MN BLUE CROSS PROV # | OTHER |