MEDICARE: CAROLYN PHELPS PHDLP LLC

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	261QM0801X	Mental Health Clinic/Center (Including Community Mental Health Center)	LP3015	MN

General Provider Information

NPI Number	:	1710467071
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CAROLYN PHELPS PHDLP LLC

Provider Business Mailing Address
First Line	:	302 W SUPERIOR ST STE 502
Second Line	:
City	:	DULUTH
State	:	MN
Zip	:	55802-5115
Country	:	US
Telephone Number	:	218-341-2834
Fax Number	:

Provider Business Practice Location Address
First Line	:	302 W SUPERIOR ST STE 502
Second Line	:
City	:	DULUTH
State	:	MN
Zip	:	55802-5115
Country	:	US
Telephone Number	:	218-341-2834
Fax Number	:

Authorized Official
Title or Position	:	PSYCHOLOGIST
Name	:	DR. CAROLYN PHELPS
Credential	:	PHD
Telephone Number	:	218-341-2834

Provider Enumeration Date	:	08/16/2018
Last Update Date	:	08/16/2018

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