Healthcare Provider Details

I. General information

NPI: 1033344031
Provider Name (Legal Business Name): CAROLYNNE J MOFFAT LMFT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/19/2009
Last Update Date: 05/19/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7800 METRO PKWY SUITE 300
BLOOMINGTON MN
55425-1514
US

IV. Provider business mailing address

7800 METRO PKWY SUITE 300
BLOOMINGTON MN
55425-1514
US

V. Phone/Fax

Practice location:
  • Phone: 651-278-7607
  • Fax: 952-851-9618
Mailing address:
  • Phone: 651-278-7607
  • Fax: 952-851-9618

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number1737
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: