Provider Demographics
NPI:1245579697
Name:DEVRIENDT, CALLIE SUE (LICSW)
Entity Type:Individual
Prefix:MRS
First Name:CALLIE
Middle Name:SUE
Last Name:DEVRIENDT
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:102 W 1ST ST
Mailing Address - Street 2:
Mailing Address - City:DULUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55802-2006
Mailing Address - Country:US
Mailing Address - Phone:218-722-7431
Mailing Address - Fax:218-722-0850
Practice Address - Street 1:102 W 1ST ST
Practice Address - Street 2:
Practice Address - City:DULUTH
Practice Address - State:MN
Practice Address - Zip Code:55802-2006
Practice Address - Country:US
Practice Address - Phone:218-722-7431
Practice Address - Fax:218-722-0850
Is Sole Proprietor?:No
Enumeration Date:2013-02-05
Last Update Date:2014-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN204021041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN20402OtherSTATE LICENSE NUMBER