Provider Demographics
NPI:1295070415
Name:DILLE, MARTHA E (MS LP)
Entity type:Individual
Prefix:
First Name:MARTHA
Middle Name:E
Last Name:DILLE
Suffix:
Gender:F
Credentials:MS LP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16982 DEWITTE AVE SW
Mailing Address - Street 2:
Mailing Address - City:PRIOR LAKE
Mailing Address - State:MN
Mailing Address - Zip Code:55372-2310
Mailing Address - Country:US
Mailing Address - Phone:952-237-6168
Mailing Address - Fax:
Practice Address - Street 1:525 PORTLAND AVE
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55415-1533
Practice Address - Country:US
Practice Address - Phone:612-964-1778
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-11-28
Last Update Date:2012-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN3470103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist