Provider Demographics
NPI:1710196522
Name:DUKE, BILL J
Entity Type:Individual
Prefix:DR
First Name:BILL
Middle Name:J
Last Name:DUKE
Suffix:
Gender:M
Credentials:
Other - Prefix:PROF
Other - First Name:BILL
Other - Middle Name:J
Other - Last Name:DUKE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MA, PHD
Mailing Address - Street 1:420 CENTER AVE STE 7
Mailing Address - Street 2:
Mailing Address - City:MOORHEAD
Mailing Address - State:MN
Mailing Address - Zip Code:56560-1962
Mailing Address - Country:US
Mailing Address - Phone:701-241-9281
Mailing Address - Fax:701-298-8321
Practice Address - Street 1:420 CENTER AVE STE 7
Practice Address - Street 2:
Practice Address - City:MOORHEAD
Practice Address - State:MN
Practice Address - Zip Code:56560-1962
Practice Address - Country:US
Practice Address - Phone:701-241-9281
Practice Address - Fax:701-298-8321
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-21
Last Update Date:2015-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP1881103TC2200X
CAPSY 14903103TC2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND1455056Medicaid