MEDICARE: CAROLYN THERESE PLASCH

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	106S00000X	Behavior Technician

General Provider Information

NPI Number	:	1639831100
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CAROLYN THERESE PLASCH

Provider Business Mailing Address
First Line	:	3007 HARBOR LN N STE 200
Second Line	:
City	:	PLYMOUTH
State	:	MN
Zip	:	55447-5103
Country	:	US
Telephone Number	:	612-445-8314
Fax Number	:	800-513-7773

Provider Business Practice Location Address
First Line	:	1912 CLINTON AVE APT 108
Second Line	:
City	:	MINNEAPOLIS
State	:	MN
Zip	:	55404-2755
Country	:	US
Telephone Number	:	651-497-8332
Fax Number	:

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

Provider Enumeration Date	:	10/12/2021
Last Update Date	:	10/12/2021

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