{
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"FirstLineMailingAddress": "6357 MERRIMAC LN N",
"SecondLineMailingAddress": null,
"MailingAddressCityName": "MAPLE GROVE",
"MailingAddressStateName": "MN",
"MailingAddressPostalCode": "55311-3835",
"MailingAddressCountryCode": "US",
"MailingAddressTelephoneNumber": "218-256-7570",
"MailingAddressFaxNumber": "877-514-9201",
"FirstLinePracticeLocationAddress": "4300 BAKER RD STE 200",
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"PracticeLocationAddressCityName": "MINNETONKA",
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"PracticeLocationAddressTelephoneNumber": "763-200-6161",
"PracticeLocationAddressFaxNumber": "877-514-9201",
"EnumerationDate": "08/06/2013",
"LastUpdateDate": "09/06/2023",
"NPIDeactivationReasonCode": null,
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"NPIDeactivationDate": null,
"NPIReactivationDate": null,
"GenderCode": null,
"Gender": null,
"AuthorizedOfficialLastName": "DICKSON",
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"AuthorizedOfficialCredential": "DNP, APRN, PMHNP",
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"Taxonomies": {
"Taxonomy": {
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"TaxonomyName": "Psychiatric/Mental Health Nurse Practitioner",
"LicenseNumber": "CNP-1591",
"LicenseNumberStateCode": "MN",
"PrimaryTaxonomySwitch": "Y"
}
},
"HealthcareProviderTaxonomyGroups": {
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"HealthcareProviderTaxonomyGroupDescription": "Single Specialty Group - A business group of one or more individual practitioners, all of who practice with the same area of specialization."
}
}
}
}