1033156393 NPI number — MR. CRAIG L. WEICKERT LICSW

Table of content: MR. CRAIG L. WEICKERT LICSW (NPI 1033156393)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1033156393 NPI number — MR. CRAIG L. WEICKERT LICSW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WEICKERT
Provider First Name:
CRAIG
Provider Middle Name:
L.
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
LICSW
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
WEICKERT
Provider Other First Name:
CRAIG
Provider Other Middle Name:
L.
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
MSW
Provider Other Last Name Type Code:
2

NPI Number Information

NPI Number:
1033156393
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:
904 18TH ST N
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MOORHEAD
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
56560-1826
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
218-287-4484
Provider Business Mailing Address Fax Number:
218-233-8627

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1010 32ND AVE S
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MOORHEAD
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
56560-5001
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
218-233-7524
Provider Business Practice Location Address Fax Number:
218-233-8627
Provider Enumeration Date:
06/02/2006

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:  12584 , 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: 116414 . This is a "UCARE MINNESOTA" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 1033073 . This is a "PREFERREDONE" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 29A23WE . This is a "BLUE SHIELD OF MINNESOTA" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 22802 . This is a "NORTH DAKOTA BLUE SHIELD" identifier , issued by the state of ( ND ) . This identifiers is of the category "OTHER".
  • Identifier: 62=67001 . This is a "UNITED BEHAVIORAL HEALTH" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: HP37867 . This is a "HEALTHPARTNERS" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".




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