Provider Demographics
NPI:1952931586
Name:MCKIBBEN, CORIE STEWART (MSW, LICSW)
Entity Type:Individual
Prefix:
First Name:CORIE
Middle Name:STEWART
Last Name:MCKIBBEN
Suffix:
Gender:F
Credentials:MSW, LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1109 RINGROCK RD
Mailing Address - Street 2:
Mailing Address - City:ELY
Mailing Address - State:MN
Mailing Address - Zip Code:55731-8235
Mailing Address - Country:US
Mailing Address - Phone:218-216-8467
Mailing Address - Fax:218-261-9083
Practice Address - Street 1:10 N 1ST AVE E STE 202
Practice Address - Street 2:
Practice Address - City:ELY
Practice Address - State:MN
Practice Address - Zip Code:55731-1473
Practice Address - Country:US
Practice Address - Phone:218-216-8467
Practice Address - Fax:218-261-9083
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-23
Last Update Date:2021-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN254281041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical