MEDICARE: DEVIN RAE HENDRICKSON 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	1041C0700X	Clinical Social Worker	29861	MN

General Provider Information

NPI Number	:	1447025713
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DEVIN RAE HENDRICKSON LICSW

Provider Business Mailing Address
First Line	:	1094 SAINT CLAIR AVE
Second Line	:
City	:	SAINT PAUL
State	:	MN
Zip	:	55105-3266
Country	:	US
Telephone Number	:	952-686-3652
Fax Number	:

Provider Business Practice Location Address
First Line	:	1205 GRAND AVE
Second Line	:
City	:	SAINT PAUL
State	:	MN
Zip	:	55105-2634
Country	:	US
Telephone Number	:	612-520-9090
Fax Number	:

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

Provider Enumeration Date	:	11/16/2023
Last Update Date	:	11/16/2023

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