Healthcare Provider Details

I. General information

NPI: 1417131103
Provider Name (Legal Business Name): CARL PETER SPORER LICSW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

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

III. Provider practice location address

1919 UNIVERSITY AVE W STE 6
SAINT PAUL MN
55104-3453
US

IV. Provider business mailing address

6901 W 84TH ST APT 363
BLOOMINGTON MN
55438-3107
US

V. Phone/Fax

Practice location:
  • Phone: 651-641-1555
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number05957
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: