Provider Demographics
NPI:1033156393
Name:WEICKERT, CRAIG L (LICSW)
Entity Type:Individual
Prefix:MR
First Name:CRAIG
Middle Name:L
Last Name:WEICKERT
Suffix:
Gender:M
Credentials:LICSW
Other - Prefix:
Other - First Name:CRAIG
Other - Middle Name:L
Other - Last Name:WEICKERT
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MSW
Mailing Address - Street 1:904 18TH ST N
Mailing Address - Street 2:
Mailing Address - City:MOORHEAD
Mailing Address - State:MN
Mailing Address - Zip Code:56560-1826
Mailing Address - Country:US
Mailing Address - Phone:218-287-4484
Mailing Address - Fax:218-233-8627
Practice Address - Street 1:1010 32ND AVE S
Practice Address - Street 2:
Practice Address - City:MOORHEAD
Practice Address - State:MN
Practice Address - Zip Code:56560-5001
Practice Address - Country:US
Practice Address - Phone:218-233-7524
Practice Address - Fax:218-233-8627
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN125841041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN116414OtherUCARE MINNESOTA
MN1033073OtherPREFERREDONE
MN29A23WEOtherBLUE SHIELD OF MINNESOTA
ND22802OtherNORTH DAKOTA BLUE SHIELD
MN62=67001OtherUNITED BEHAVIORAL HEALTH
MNHP37867OtherHEALTHPARTNERS