=====================================================
General NPI Number Information
=====================================================
NPI Number | 1013442557
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ASHLEY CARLSON LADC
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/21/2017
-----------------------------------------------------
Last Update Date | 04/21/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 105 6TH AVE S
-----------------------------------------------------
City | PRINCETON
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55371-1819
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 763-308-0006
-----------------------------------------------------
Fax | 763-631-0339
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 204 1ST ST NW
-----------------------------------------------------
City | ELK RIVER
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55330
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 320-237-4999
-----------------------------------------------------
Fax | 763-631-0339
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YA0400X
-----------------------------------------------------
Taxonomy Name | Addiction (Substance Use Disorder) Counselor
-----------------------------------------------------
License Number | 304770
-----------------------------------------------------
License Number State | MN
-----------------------------------------------------