MEDICARE: GERALDINE DELORES CARLTON LADC

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	101YA0400X	Addiction (Substance Use Disorder) Counselor	301856	MN

General Provider Information

NPI Number	:	1942176268
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	GERALDINE DELORES CARLTON LADC

Provider Business Mailing Address
First Line	:	2940 36TH AVE S
Second Line	:
City	:	MINNEAPOLIS
State	:	MN
Zip	:	55406-1716
Country	:	US
Telephone Number	:	612-423-0012
Fax Number	:	651-372-8781

Provider Business Practice Location Address
First Line	:	2940 36TH AVE S
Second Line	:
City	:	MINNEAPOLIS
State	:	MN
Zip	:	55406-1716
Country	:	US
Telephone Number	:	612-423-0012
Fax Number	:	651-372-8781

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

Provider Enumeration Date	:	10/14/2025
Last Update Date	:	10/14/2025

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