Healthcare Provider Details

I. General information

NPI: 1831519602
Provider Name (Legal Business Name): CARLY DIRLAM M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/21/2014
Last Update Date: 03/11/2021
Certification Date: 03/11/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2855 CAMPUS DRIVE ABBOTT NORTHWESTERN - WESTHEALTH, SUITE 660
PLYMOUTH MN
55441
US

IV. Provider business mailing address

2450 RIVERSIDE AVE
MINNEAPOLIS MN
55454-1450
US

V. Phone/Fax

Practice location:
  • Phone: 763-577-7900
  • Fax: 763-577-7905
Mailing address:
  • Phone: 612-273-9824
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number59886
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: