MEDICARE: CARLY RAE SPOTTS-FALZONE

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YM0800X	Mental Health Counselor	4621	MN

General Provider Information

NPI Number	:	1164241535
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CARLY RAE SPOTTS-FALZONE

Provider Business Mailing Address
First Line	:	6600 HILLSIDE LN
Second Line	:
City	:	EDINA
State	:	MN
Zip	:	55439-1318
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	708 N 1ST ST STE 234
Second Line	:
City	:	MINNEAPOLIS
State	:	MN
Zip	:	55401-1145
Country	:	US
Telephone Number	:	952-378-0398
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/03/2024
Last Update Date	:	10/03/2024

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