=====================================================
General NPI Number Information
=====================================================
NPI Number | 1972672087
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DAWN DIANA DRAAYER-THIBODEAU LICSW
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/06/2006
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4500 PARK GLEN RD STE 155
-----------------------------------------------------
City | ST LOUIS PARK
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55416-4888
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 952-334-1213
-----------------------------------------------------
Fax | 952-928-9774
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 12848 INDEPENDENCE AVE
-----------------------------------------------------
City | SAVAGE
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55378-1189
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 952-334-1213
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | 15185
-----------------------------------------------------
License Number State | MN
-----------------------------------------------------