Healthcare Provider Details

I. General information

NPI: 1912351545
Provider Name (Legal Business Name): DAVID LEWIS FARLEY LICSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/20/2016
Last Update Date: 09/29/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1700 UNIVERSITY AVE W 6TH FLOOR
SAINT PAUL MN
55104-3727
US

IV. Provider business mailing address

1700 UNIVERSITY AVE W 6TH FLOOR
SAINT PAUL MN
55104-3727
US

V. Phone/Fax

Practice location:
  • Phone: 651-232-2273
  • Fax: 651-232-4953
Mailing address:
  • Phone: 651-232-2273
  • Fax: 651-232-4953

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number21217
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: