Healthcare Provider Details

I. General information

NPI: 1366476277
Provider Name (Legal Business Name): MICHAEL JOHN CARLE MSSW LICSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/10/2006
Last Update Date: 06/17/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9075 QUADAY AVE NE SUITE 102
OTSEGO MN
55330-6672
US

IV. Provider business mailing address

1900 SILVER LAKE RD NW SUITE 110
NEW BRIGHTON MN
55112-1786
US

V. Phone/Fax

Practice location:
  • Phone: 763-746-9492
  • Fax: 763-746-3685
Mailing address:
  • Phone: 651-628-9566
  • Fax: 651-628-0411

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number7229
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: