Healthcare Provider Details

I. General information

NPI: 1366989113
Provider Name (Legal Business Name): CASEY DICKINSON LICSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/31/2017
Last Update Date: 04/04/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3900 NORTHWOODS DR
ARDEN HILLS MN
55112-6966
US

IV. Provider business mailing address

1100 GLENWOOD AVE
MINNEAPOLIS MN
55405-1430
US

V. Phone/Fax

Practice location:
  • Phone: 651-787-9600
  • Fax:
Mailing address:
  • Phone: 612-871-1454
  • Fax: 612-871-1505

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number23434
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: