Healthcare Provider Details

I. General information

NPI: 1760865448
Provider Name (Legal Business Name): HEATHER CONLEY LICSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/30/2015
Last Update Date: 07/28/2020
Certification Date: 07/28/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9245 QUANTRELLE AVE NE
OTSEGO MN
55330-0168
US

IV. Provider business mailing address

1900 SILVER LAKE RD NW STE 110
NEW BRIGHTON MN
55112-1789
US

V. Phone/Fax

Practice location:
  • Phone: 763-308-8619
  • Fax: 763-746-3685
Mailing address:
  • Phone: 651-419-4351
  • Fax: 651-628-0411

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number20521
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: