Healthcare Provider Details

I. General information

NPI: 1881133403
Provider Name (Legal Business Name): CHRISTINE LYNN GEDICKE LICSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/15/2017
Last Update Date: 02/15/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2250 NW 26TH ST
OWATONNA MN
55060-5503
US

IV. Provider business mailing address

2250 NW 26TH ST
OWATONNA MN
55060-5503
US

V. Phone/Fax

Practice location:
  • Phone: 507-977-2574
  • Fax: 507-977-2373
Mailing address:
  • Phone: 507-977-2574
  • Fax: 507-977-2373

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number19514
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: