Basic Information
| Provider Information | |||||||||
| NPI: | 1710986989 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | FAMILY SERVICE OF WINONA | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | FAMILY SERVICE OF WINONA - MARGARET SIMPSON HOME | ||||||||
| OtherOrganizationType: | 4 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
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| OtherCredential: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 66 E. 3RD STREET #201 | ||||||||
| Address2: | |||||||||
| City: | WINONA | ||||||||
| State: | MN | ||||||||
| PostalCode: | 55987 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5074627292 | ||||||||
| FaxNumber: | 5074579887 | ||||||||
| Practice Location | |||||||||
| Address1: | 66 E. 3RD STREET #201 | ||||||||
| Address2: | |||||||||
| City: | WINONA | ||||||||
| State: | MN | ||||||||
| PostalCode: | 55987 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5074627292 | ||||||||
| FaxNumber: | 5074579887 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/19/2005 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | PETZ | ||||||||
| AuthorizedOfficialFirstName: | DIANE | ||||||||
| AuthorizedOfficialMiddleName: | V. | ||||||||
| AuthorizedOfficialTitleorPosition: | ADMIN MANAGER/THERAPIST | ||||||||
| AuthorizedOfficialTelephone: | 5074527292 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MS. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | MS/LP | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | 8677 | MN | X | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Social Worker | 104100000X | 8882 | MN | X | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Social Worker | 103T00000X | LP4439 | MN | X | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Psychologist | 103T00000X | LP4392 | MN | X | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Psychologist | 103T00000X | LP1219 | MN | X | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Psychologist | 103T00000X | LP3132 | MN | X | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Psychologist | 103T00000X | LP0177 | MN | X | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Psychologist |
ID Information
| ID | Type | State | Issuer | Description | 14809 | 01 | HEALTHPARTNERS | OTHER | 01015397 | 01 | PREFERRED ONE | OTHER | 57490FA | 01 | BCBS | OTHER | 38076T0 | 01 | BCBS | OTHER | E341 | 01 | MN | UCARE | OTHER |