Provider Demographics
NPI:1972672087
Name:DRAAYER-THIBODEAU, DAWN DIANA (LICSW)
Entity Type:Individual
Prefix:MRS
First Name:DAWN
Middle Name:DIANA
Last Name:DRAAYER-THIBODEAU
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 1:12848 INDEPENDENCE AVE
Mailing Address - Street 2:
Mailing Address - City:SAVAGE
Mailing Address - State:MN
Mailing Address - Zip Code:55378-1189
Mailing Address - Country:US
Mailing Address - Phone:952-334-1213
Mailing Address - Fax:
Practice Address - Street 1:4500 PARK GLEN RD STE 155
Practice Address - Street 2:
Practice Address - City:ST LOUIS PARK
Practice Address - State:MN
Practice Address - Zip Code:55416-4888
Practice Address - Country:US
Practice Address - Phone:952-334-1213
Practice Address - Fax:952-928-9774
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN151851041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN78612312-00Medicaid