MEDICARE: DIRT GROUP GLOBAL

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker

General Provider Information

NPI Number	:	1114759016
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DIRT GROUP GLOBAL

Provider Business Mailing Address
First Line	:	992 DAYTON AVE APT 2
Second Line	:
City	:	SAINT PAUL
State	:	MN
Zip	:	55104-6559
Country	:	US
Telephone Number	:	320-220-2551
Fax Number	:

Provider Business Practice Location Address
First Line	:	992 DAYTON AVE APT 2
Second Line	:
City	:	SAINT PAUL
State	:	MN
Zip	:	55104-6559
Country	:	US
Telephone Number	:	320-220-2551
Fax Number	:

Authorized Official
Title or Position	:	EXECUTIVE DIRECTOR
Name	:	KENNETH STEVEN TURCK
Credential	:	MSW, LICSW
Telephone Number	:	320-220-2551

Provider Enumeration Date	:	08/19/2024
Last Update Date	:	08/19/2024

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