Healthcare Provider Details

I. General information

NPI: 1093630972
Provider Name (Legal Business Name): ALYSSA ANN DEFOE LGSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/11/2026
Last Update Date: 08/11/2026
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4325 GRAND AVE
DULUTH MN
55807-2730
US

IV. Provider business mailing address

2222 E. 5TH STREET
SUPERIOR WI
54880-3709
US

V. Phone/Fax

Practice location:
  • Phone: 218-722-1497
  • Fax: 218-722-6239
Mailing address:
  • Phone: 715-392-1955
  • Fax: 715-392-1935

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number135896-121
License Number StateWI
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number30349
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: