Provider Demographics
NPI:1144795162
Name:HOMSTAD, BAILEY M (MSW, LICSW)
Entity Type:Individual
Prefix:
First Name:BAILEY
Middle Name:M
Last Name:HOMSTAD
Suffix:
Gender:F
Credentials:MSW, LICSW
Other - Prefix:
Other - First Name:BAILEY
Other - Middle Name:M
Other - Last Name:MOEHRKE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:1401 EAST 1ST STREET
Mailing Address - Street 2:
Mailing Address - City:DULUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55805-2407
Mailing Address - Country:US
Mailing Address - Phone:218-728-4491
Mailing Address - Fax:218-730-2367
Practice Address - Street 1:1406 E 2ND ST
Practice Address - Street 2:
Practice Address - City:DULUTH
Practice Address - State:MN
Practice Address - Zip Code:55805-2378
Practice Address - Country:US
Practice Address - Phone:218-624-5683
Practice Address - Fax:218-624-5736
Is Sole Proprietor?:No
Enumeration Date:2018-10-05
Last Update Date:2018-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN233271041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical