Provider Demographics
NPI:1578076154
Name:DALZELL, ANDREA LEE (MSW, LICSW)
Entity Type:Individual
Prefix:
First Name:ANDREA
Middle Name:LEE
Last Name:DALZELL
Suffix:
Gender:F
Credentials:MSW, LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:916 S 7TH ST
Mailing Address - Street 2:
Mailing Address - City:BRAINERD
Mailing Address - State:MN
Mailing Address - Zip Code:56401-4035
Mailing Address - Country:US
Mailing Address - Phone:218-851-6906
Mailing Address - Fax:
Practice Address - Street 1:823 MAPLE ST
Practice Address - Street 2:
Practice Address - City:BRAINERD
Practice Address - State:MN
Practice Address - Zip Code:56401-3770
Practice Address - Country:US
Practice Address - Phone:218-454-7205
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-11-06
Last Update Date:2017-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN242651041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical