MEDICARE: DARRELL EUGENE BARNACK LICSW

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	104100000X	Social Worker	1001-123	WI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1013664	OTHER		PREFERRED ONE
2	52Q13BA	OTHER	MN	BCBS OF MN

General Provider Information

NPI Number	:	1346295540
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DARRELL EUGENE BARNACK LICSW

Provider Business Mailing Address
First Line	:	400 E 3RD ST
Second Line	:
City	:	DULUTH
State	:	MN
Zip	:	55805-1951
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	3500 TOWER AVE
Second Line	:
City	:	SUPERIOR
State	:	WI
Zip	:	54880-5335
Country	:	US
Telephone Number	:	715-395-5454
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/24/2006
Last Update Date	:	07/08/2007

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