Provider Demographics
NPI:1497112254
Name:DWINNELL-DILLON, KIMBERLY JEANE (LICSW)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:JEANE
Last Name:DWINNELL-DILLON
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 1:106 NORWAY CT
Mailing Address - Street 2:
Mailing Address - City:BRAINERD
Mailing Address - State:MN
Mailing Address - Zip Code:56401-4500
Mailing Address - Country:US
Mailing Address - Phone:218-232-3089
Mailing Address - Fax:
Practice Address - Street 1:13045 FALCON DR STE 100
Practice Address - Street 2:
Practice Address - City:BAXTER
Practice Address - State:MN
Practice Address - Zip Code:56425-4201
Practice Address - Country:US
Practice Address - Phone:218-829-9307
Practice Address - Fax:218-829-7649
Is Sole Proprietor?:No
Enumeration Date:2016-01-25
Last Update Date:2016-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN221871041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical