Healthcare Provider Details

I. General information

NPI: 1700478625
Provider Name (Legal Business Name): CARLY CRISTINE MCCORMACK LADC, LPCC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: CARLY CRISTINE RUTTER

II. Dates (important events)

Enumeration Date: 02/11/2021
Last Update Date: 09/02/2026
Certification Date: 09/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12775 SWALLOW ST NW
COON RAPIDS MN
55448-2587
US

IV. Provider business mailing address

PO BOX 43
ANOKA MN
55303-0019
US

V. Phone/Fax

Practice location:
  • Phone: 701-850-7438
  • Fax:
Mailing address:
  • Phone: 612-208-9541
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number3936
License Number StateMN
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number3936
License Number StateMN
# 3
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number305956
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: