Healthcare Provider Details

I. General information

NPI: 1124450556
Provider Name (Legal Business Name): CARRIE LYNN THOMPSON WIDMER LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/08/2013
Last Update Date: 08/10/2023
Certification Date: 08/10/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

416 KUNDERT ST
TURTLE LAKE ND
58575-4205
US

IV. Provider business mailing address

416 KUNDERT ST
TURTLE LAKE ND
58575-4205
US

V. Phone/Fax

Practice location:
  • Phone: 701-448-9225
  • Fax: 701-448-2056
Mailing address:
  • Phone: 701-448-9225
  • Fax: 701-448-2056

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number4938
License Number StateND
# 2
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: