=====================================================
General NPI Number Information
=====================================================
NPI Number | 1023667326
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CARRIE SALSNESS LADC
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/09/2019
-----------------------------------------------------
Last Update Date | 09/09/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3705 PARK CENTER BLVD
-----------------------------------------------------
City | ST LOUIS PARK
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55416-2504
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 952-405-7643
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6099 SUMTER AVE N
-----------------------------------------------------
City | NEW HOPE
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55428-2819
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 952-221-3186
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
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 | 301684
-----------------------------------------------------
License Number State | MN
-----------------------------------------------------