Provider Demographics
NPI:1962903203
Name:WYMORE, JULIE MAE (MSW, LICSW)
Entity type:Individual
Prefix:
First Name:JULIE
Middle Name:MAE
Last Name:WYMORE
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 1:507 22ND AVE E STE 1
Mailing Address - Street 2:
Mailing Address - City:ALEXANDRIA
Mailing Address - State:MN
Mailing Address - Zip Code:56308-5186
Mailing Address - Country:US
Mailing Address - Phone:320-762-5124
Mailing Address - Fax:320-762-2422
Practice Address - Street 1:507 22ND AVE E STE 1
Practice Address - Street 2:
Practice Address - City:ALEXANDRIA
Practice Address - State:MN
Practice Address - Zip Code:56308-5186
Practice Address - Country:US
Practice Address - Phone:320-762-5124
Practice Address - Fax:320-762-2422
Is Sole Proprietor?:No
Enumeration Date:2018-02-22
Last Update Date:2018-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20170387531041C0700X
MN227121041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical