Healthcare Provider Details

I. General information

NPI: 1093737736
Provider Name (Legal Business Name): ERICA CHRISTINE GWILLIM MSW, LICSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/24/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1900 SILVER LAKE RD NW SUITE 110
NEW BRIGHTON MN
55112-1786
US

IV. Provider business mailing address

1900 SILVER LAKE RD NW SUITE 110
NEW BRIGHTON MN
55112-1786
US

V. Phone/Fax

Practice location:
  • Phone: 651-628-9253
  • Fax: 651-631-8789
Mailing address:
  • Phone: 651-628-9253
  • Fax: 651-631-8789

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number15072
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: