Provider Demographics
NPI:1508922477
Name:DIMOCK, PETER TRIER (MSW)
Entity Type:Individual
Prefix:MR
First Name:PETER
Middle Name:TRIER
Last Name:DIMOCK
Suffix:
Gender:M
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:357 KELLOGG BLVD E
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55101-1411
Mailing Address - Country:US
Mailing Address - Phone:651-226-8075
Mailing Address - Fax:
Practice Address - Street 1:357 KELLOGG BLVD E
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55101-1411
Practice Address - Country:US
Practice Address - Phone:651-226-8075
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN000191041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN00019OtherLICSW - MN