Healthcare Provider Details

I. General information

NPI: 1912436833
Provider Name (Legal Business Name): STARLA MARIE WESLEY LADC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: STARLA MARIE MOORE

II. Dates (important events)

Enumeration Date: 06/05/2017
Last Update Date: 01/03/2020
Certification Date: 01/03/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3300 COUNTY ROAD 10 STE 300A
BROOKLYN CENTER MN
55429-3066
US

IV. Provider business mailing address

3300 COUNTY 10, SUITE 300 A
BROOKLYN CENTER MN
55429
US

V. Phone/Fax

Practice location:
  • Phone: 612-759-5654
  • Fax:
Mailing address:
  • Phone: 612-759-5654
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number304663
License Number StateMN
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: