Healthcare Provider Details

I. General information

NPI: 1295936946
Provider Name (Legal Business Name): COMMUNITY DIAGNOSTICS AND CONSULTATION, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/30/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5642 HALIE RD
DULUTH MN
55810-2166
US

IV. Provider business mailing address

5642 HALIE RD
DULUTH MN
55810-2166
US

V. Phone/Fax

Practice location:
  • Phone: 218-591-7057
  • Fax:
Mailing address:
  • Phone: 218-591-7057
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code364SP0809X
TaxonomyAdult Psychiatric/Mental Health Clinical Nurse Specialist
License NumberR110631-4
License Number StateMN

VIII. Authorized Official

Name: MRS. THERESA MARIE CARR
Title or Position: PRESIDENT
Credential: MA, RN, CNS
Phone: 218-591-7057