Healthcare Provider Details

I. General information

NPI: 1972829943
Provider Name (Legal Business Name): DEBRA CARTER-BARTH
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/15/2010
Last Update Date: 04/15/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

303 1ST AVE NE STE 240
FARIBAULT MN
55021-5268
US

IV. Provider business mailing address

303 1ST AVE. N.E. STE 240
FARIBAULT MN
55021-5379
US

V. Phone/Fax

Practice location:
  • Phone: 507-412-1468
  • Fax: 507-331-8677
Mailing address:
  • Phone: 507-412-1468
  • Fax: 507-331-8677

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number17263
License Number StateMN
# 2
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number17263
License Number StateMN

VIII. Authorized Official

Name: DEBRA LYNN CARTER-BARTH
Title or Position: PSYCHOTHERAPIST / OWNER
Credential: LICSW
Phone: 507-412-1468