Provider Demographics
NPI:1215041694
Name:DEJDAR, ROBERT JOHN (LICSW)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:JOHN
Last Name:DEJDAR
Suffix:
Gender:M
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1415 CUTTERS LN
Mailing Address - Street 2:
Mailing Address - City:EAGAN
Mailing Address - State:MN
Mailing Address - Zip Code:55122-3800
Mailing Address - Country:US
Mailing Address - Phone:651-683-0429
Mailing Address - Fax:
Practice Address - Street 1:1415 CUTTERS LN
Practice Address - Street 2:
Practice Address - City:EAGAN
Practice Address - State:MN
Practice Address - Zip Code:55122-3800
Practice Address - Country:US
Practice Address - Phone:651-683-0429
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN23611041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical