Healthcare Provider Details

I. General information

NPI: 1649366808
Provider Name (Legal Business Name): DIANE RAE GRINNELL LICSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/05/2006
Last Update Date: 03/21/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3450 OLEARY LN
EAGAN MN
55123-2340
US

IV. Provider business mailing address

12773 ETHELTON WAY
APPLE VALLEY MN
55124-7802
US

V. Phone/Fax

Practice location:
  • Phone: 651-454-0114
  • Fax: 651-454-3492
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number8942
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: