Provider Demographics
NPI:1922568641
Name:DICK, MICHELLE MARIE (LICSW)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:MARIE
Last Name:DICK
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 FREEMAN DR
Mailing Address - Street 2:
Mailing Address - City:SAINT PETER
Mailing Address - State:MN
Mailing Address - Zip Code:56082-3504
Mailing Address - Country:US
Mailing Address - Phone:507-985-2190
Mailing Address - Fax:651-431-7676
Practice Address - Street 1:100 FREEMAN DR
Practice Address - Street 2:
Practice Address - City:SAINT PETER
Practice Address - State:MN
Practice Address - Zip Code:56082-3504
Practice Address - Country:US
Practice Address - Phone:507-985-2190
Practice Address - Fax:651-431-7676
Is Sole Proprietor?:Yes
Enumeration Date:2019-03-20
Last Update Date:2019-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN172291041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical