Provider Demographics
NPI:1770132284
Name:DIONNE L SPOONER, LICSW
Entity type:Organization
Organization Name:DIONNE L SPOONER, LICSW
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DIONNE
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:SPOONER
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:701-721-8978
Mailing Address - Street 1:10430 COUNTY ROAD 15 W
Mailing Address - Street 2:
Mailing Address - City:MINOT
Mailing Address - State:ND
Mailing Address - Zip Code:58703-9629
Mailing Address - Country:US
Mailing Address - Phone:701-721-8978
Mailing Address - Fax:
Practice Address - Street 1:10 3RD AVE SW STE 206
Practice Address - Street 2:
Practice Address - City:MINOT
Practice Address - State:ND
Practice Address - Zip Code:58701-3893
Practice Address - Country:US
Practice Address - Phone:701-721-8978
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-09-06
Last Update Date:2019-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND1461742Medicaid