Healthcare Provider Details

I. General information

NPI: 1134815640
Provider Name (Legal Business Name): SIERRA NICOLE CARTER MSW, LICSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/17/2023
Last Update Date: 05/06/2024
Certification Date: 05/06/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12800 WHITEWATER DR STE 100
MINNETONKA MN
55343-9347
US

IV. Provider business mailing address

4240 PARK GLEN RD
ST LOUIS PARK MN
55416-5427
US

V. Phone/Fax

Practice location:
  • Phone: 952-592-3405
  • Fax:
Mailing address:
  • Phone: 612-925-6033
  • Fax: 612-925-8496

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number27027
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: