Provider Demographics
NPI:1649366808
Name:GRINNELL, DIANE RAE (LICSW)
Entity type:Individual
Prefix:
First Name:DIANE
Middle Name:RAE
Last Name:GRINNELL
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 1:12773 ETHELTON WAY
Mailing Address - Street 2:
Mailing Address - City:APPLE VALLEY
Mailing Address - State:MN
Mailing Address - Zip Code:55124-7802
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3450 OLEARY LN
Practice Address - Street 2:
Practice Address - City:EAGAN
Practice Address - State:MN
Practice Address - Zip Code:55123-2340
Practice Address - Country:US
Practice Address - Phone:651-454-0114
Practice Address - Fax:651-454-3492
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-05
Last Update Date:2018-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN89421041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN60F01GROtherBCBS
MN62-60394OtherUBH
MN018757700OtherMN CARE
FM123136OtherUCARE
MNHP17977OtherHEALTHPARTNERS
MN41-1546550OtherBHP