Provider Demographics
NPI:1629130075
Name:KNOFLICEK, WILLIAM J (PHD)
Entity Type:Individual
Prefix:
First Name:WILLIAM
Middle Name:J
Last Name:KNOFLICEK
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:WILLIAM
Other - Middle Name:J
Other - Last Name:KNOFLICEK
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PHD
Mailing Address - Street 1:2400 S. MINNESOTA AVE
Mailing Address - Street 2:STE 100
Mailing Address - City:SIOUX FALLS
Mailing Address - State:SD
Mailing Address - Zip Code:57105-3762
Mailing Address - Country:US
Mailing Address - Phone:605-322-7510
Mailing Address - Fax:605-322-6475
Practice Address - Street 1:4400 W 69TH ST
Practice Address - Street 2:STE. 500
Practice Address - City:SIOUX FALLS
Practice Address - State:SD
Practice Address - Zip Code:57108-8171
Practice Address - Country:US
Practice Address - Phone:605-322-7580
Practice Address - Fax:605-322-7579
Is Sole Proprietor?:No
Enumeration Date:2006-12-14
Last Update Date:2015-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD461103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE46022474326Medicaid
SD4993504OtherWELLMARK BCBS
SD9236559OtherDAKOTACARE PROV #
MN247052700Medicaid
SD6552352Medicaid
MN99GO9KNOtherMN BLUE CROSS PROV #
SDS102725Medicare PIN
SD6552352Medicaid