MEDICARE: TRACEY LYNN KLOBUCHAR LSW

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	4667	ND
2	1041C0700X	Clinical Social Worker	4667	ND

General Provider Information

NPI Number	:	1952675860
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TRACEY LYNN KLOBUCHAR LSW

Provider Business Mailing Address
First Line	:	3175 SIENNA DR S STE 101
Second Line	:
City	:	FARGO
State	:	ND
Zip	:	58104-8910
Country	:	US
Telephone Number	:	701-922-0857
Fax Number	:

Provider Business Practice Location Address
First Line	:	3175 SIENNA DR S STE 101
Second Line	:
City	:	FARGO
State	:	ND
Zip	:	58104-8910
Country	:	US
Telephone Number	:	701-922-0857
Fax Number	:

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

Provider Enumeration Date	:	02/24/2012
Last Update Date	:	08/21/2023

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