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General NPI Number Information
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NPI Number | 1720329071
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Entity Type | Organization
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Legal Business Name | CLOQUET PSYCHOLOGICAL LLC
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Dates
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Enumeration Date | 03/12/2013
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Last Update Date | 03/12/2013
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Provider Practice Location Address
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Address Line | 605 KALLSTROM RD
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City | CLOQUET
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State | MN
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Zip | 55720-9415
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Country | US
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Telephone | 218-940-5259
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Fax |
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Provider Business Mailing Address
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Address Line | 605 KALLSTROM RD
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City | CLOQUET
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State | MN
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Zip | 55720-9415
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Country | US
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Telephone | 218-940-5259
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Fax |
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Authorized Official
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Title or Position | LICENSED PSYCHOLOGIST
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Name | DR. CAROLINE LOUISE NELSON
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Credential | PSYDLP
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Telephone | 218-940-5259
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103TC0700X
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Taxonomy Name | Clinical Psychologist
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License Number | LP4209
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License Number State | MN
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