Healthcare Provider Details

I. General information

NPI: 1013566181
Provider Name (Legal Business Name): DANIEL DIMICK, MA, LP, LMFT, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/10/2019
Last Update Date: 09/10/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

105 4TH ST E STE 304
NORTHFIELD MN
55057-2047
US

IV. Provider business mailing address

105 4TH ST E STE 304
NORTHFIELD MN
55057-2047
US

V. Phone/Fax

Practice location:
  • Phone: 507-645-6575
  • Fax: 507-645-7822
Mailing address:
  • Phone: 507-645-6575
  • Fax: 507-645-7822

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State

VIII. Authorized Official

Name: MR. DANIEL JOHN DIMICK
Title or Position: PSYCHOLOGIST
Credential: MA, LP, LMFT
Phone: 507-645-6575