Healthcare Provider Details

I. General information

NPI: 1497112254
Provider Name (Legal Business Name): KIMBERLY JEANE DWINNELL-DILLON L.I.C.S.W
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/25/2016
Last Update Date: 01/25/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13045 FALCON DR STE 100
BAXTER MN
56425-4201
US

IV. Provider business mailing address

106 NORWAY CT
BRAINERD MN
56401-4500
US

V. Phone/Fax

Practice location:
  • Phone: 218-829-9307
  • Fax: 218-829-7649
Mailing address:
  • Phone: 218-232-3089
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number22187
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: