=====================================================
General NPI Number Information
=====================================================
NPI Number | 1962127936
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KIMBERLY CHARLOTTE CARL
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/11/2022
-----------------------------------------------------
Last Update Date | 10/11/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 817 MAIN ST N
-----------------------------------------------------
City | CAMBRIDGE
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55008-1275
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 763-228-2772
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 22032 E BETHEL BLVD NE
-----------------------------------------------------
City | CEDAR
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55011-4616
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 763-228-2772
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------