Provider Demographics
NPI:1508996596
Name:DILLY, GINA A (MS LP)
Entity Type:Individual
Prefix:MS
First Name:GINA
Middle Name:A
Last Name:DILLY
Suffix:
Gender:F
Credentials:MS LP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1872 TOPAZ POINTE LANE SW
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:MN
Mailing Address - Zip Code:55902
Mailing Address - Country:US
Mailing Address - Phone:507-292-1600
Mailing Address - Fax:507-292-1600
Practice Address - Street 1:300 1ST AVE NW
Practice Address - Street 2:SUITE 20
Practice Address - City:ROCHESTER
Practice Address - State:MN
Practice Address - Zip Code:55901
Practice Address - Country:US
Practice Address - Phone:507-292-1600
Practice Address - Fax:507-292-1600
Is Sole Proprietor?:No
Enumeration Date:2007-03-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP3986103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN034DIDIOtherBCBS BLUE CROSS BLUE SHIE