1689722985 NPI number — MS. DIETRAH CHAPMAN HIATT MSW, LICSW

Table of content: MS. DIETRAH CHAPMAN HIATT MSW, LICSW (NPI 1689722985)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1689722985 NPI number — MS. DIETRAH CHAPMAN HIATT MSW, LICSW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
HIATT
Provider First Name:
DIETRAH
Provider Middle Name:
CHAPMAN
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
MSW, LICSW
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1689722985
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3140 CHOWEN AVE S APT 326
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MINNEAPOLIS
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55416-4534
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
612-362-0104
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1919 UNIVERSITY AVE W
Provider Second Line Business Practice Location Address:
SUITE 200
Provider Business Practice Location Address City Name:
SAINT PAUL
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55104-3453
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
651-266-7932
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
01/05/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 1041C0700X , with the licence number:  13950 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 443242800 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".




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