Healthcare Provider Details

I. General information

NPI: 1053973339
Provider Name (Legal Business Name): CARRIE WELLER LPCC/LADC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: CARRIE MILLIGAN

II. Dates (important events)

Enumeration Date: 07/08/2019
Last Update Date: 08/23/2024
Certification Date: 08/23/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2550 UNIVERSITY AVE W STE 435S
SAINT PAUL MN
55114-1907
US

IV. Provider business mailing address

945 17TH ST
NEWPORT MN
55055-1609
US

V. Phone/Fax

Practice location:
  • Phone: 651-647-1900
  • Fax:
Mailing address:
  • Phone: 651-468-4350
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number304302
License Number StateMN
# 2
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberCC01795
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: