Healthcare Provider Details

I. General information

NPI: 1588048912
Provider Name (Legal Business Name): TAMMIE LYN KNICK LICSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/15/2015
Last Update Date: 07/15/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6620 60TH ST NE
SPICER MN
56288-9635
US

IV. Provider business mailing address

6620 60TH ST NE
SPICER MN
56288-9635
US

V. Phone/Fax

Practice location:
  • Phone: 507-276-4015
  • Fax:
Mailing address:
  • Phone: 507-276-4015
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number13770
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: