Healthcare Provider Details

I. General information

NPI: 1154484418
Provider Name (Legal Business Name): MARY KAY CARLE LMFT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/18/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5821 MICHAEL CT
SAINT CLOUD MN
56303-0926
US

IV. Provider business mailing address

5821 MICHAEL CT
SAINT CLOUD MN
56303-0926
US

V. Phone/Fax

Practice location:
  • Phone: 320-252-5653
  • Fax:
Mailing address:
  • Phone: 320-252-5653
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberLMFT 512
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: