Provider Demographics
NPI:1558437764
Name:LOKKESMOE, DALE KNUTE (MA)
Entity Type:Individual
Prefix:
First Name:DALE
Middle Name:KNUTE
Last Name:LOKKESMOE
Suffix:
Gender:M
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10535 165TH ST W
Mailing Address - Street 2:
Mailing Address - City:LAKEVILLE
Mailing Address - State:MN
Mailing Address - Zip Code:55044-5729
Mailing Address - Country:US
Mailing Address - Phone:952-435-0022
Mailing Address - Fax:952-435-0095
Practice Address - Street 1:10535 165TH ST W
Practice Address - Street 2:
Practice Address - City:LAKEVILLE
Practice Address - State:MN
Practice Address - Zip Code:55044-5729
Practice Address - Country:US
Practice Address - Phone:952-435-0022
Practice Address - Fax:952-435-0095
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP3587103TB0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & Behavioral
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN81G04LAOtherBLUE CROSS BLUE SHIELD
MN414963OtherBEHAVIORAL HEALTH PROVIDE