MEDICARE: KAYCIE DALE

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	101YM0800X	Mental Health Counselor	27390	MN
2	1041C0700X	Clinical Social Worker	27390	MN

General Provider Information

NPI Number	:	1497354344
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KAYCIE DALE

Provider Business Mailing Address
First Line	:	1052 19TH AVE SE
Second Line	:
City	:	MINNEAPOLIS
State	:	MN
Zip	:	55414-2553
Country	:	US
Telephone Number	:	612-387-3632
Fax Number	:

Provider Business Practice Location Address
First Line	:	2124 DUPONT AVE S STE 201
Second Line	:
City	:	MINNEAPOLIS
State	:	MN
Zip	:	55405-2719
Country	:	US
Telephone Number	:	651-300-3688
Fax Number	:

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

Provider Enumeration Date	:	10/21/2020
Last Update Date	:	04/09/2024

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Directions to “ KAYCIE DALE ” Practice Location

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