Healthcare Provider Details

I. General information

NPI: 1356487227
Provider Name (Legal Business Name): MARY BETH DORNHEIM LICSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/29/2007
Last Update Date: 05/28/2024
Certification Date: 05/28/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2400 W 49TH ST
SIOUX FALLS SD
57105-6581
US

IV. Provider business mailing address

PO BOX 5074
SIOUX FALLS SD
57117-5074
US

V. Phone/Fax

Practice location:
  • Phone: 605-312-8700
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number173889
License Number StateMN
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number4781
License Number StateSD
# 3
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number19740
License Number StateMN

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier330617000
Identifier TypeOTHER
Identifier StateMN
Identifier IssuerMINNESOTA HEALTH CARE PROGRAMS
# 2
Identifier1356487227
Identifier TypeOTHER
Identifier StateMN
Identifier IssuerHEATH PARTNERS
# 3
Identifier000498910
Identifier TypeOTHER
Identifier StateMN
Identifier IssuerUBH MEDICA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: