Healthcare Provider Details

I. General information

NPI: 1063435543
Provider Name (Legal Business Name): CATHY LIANE MSLP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/25/2006
Last Update Date: 03/21/2024
Certification Date: 02/29/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4820 COUNTY ROAD 77
NISSWA MN
56468-2708
US

IV. Provider business mailing address

PO BOX 68
NISSWA MN
56468-0068
US

V. Phone/Fax

Practice location:
  • Phone: 218-821-4923
  • Fax: 218-961-4923
Mailing address:
  • Phone: 218-821-4923
  • Fax: 218-961-4923

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License NumberLP1535
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: