1568530020 NPI number — CAROLE GAIL CERA LICSW

Table of content: CAROLE GAIL CERA LICSW (NPI 1568530020)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1568530020 NPI number — CAROLE GAIL CERA LICSW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CERA
Provider First Name:
CAROLE
Provider Middle Name:
GAIL
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
LICSW
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1568530020
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5400 XERXES AVE S
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
EDINA
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55410-2457
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
952-924-4932
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
13100 WAYZATA BLVD
Provider Second Line Business Practice Location Address:
SUITE 400
Provider Business Practice Location Address City Name:
MINNETONKA
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55305-1802
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
952-546-0616
Provider Business Practice Location Address Fax Number:
952-573-1778
Provider Enumeration Date:
12/01/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 1041C0700X , with the licence number:  04515 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 793557900 . This is a "MEDICAL ASSISTANCE" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 6220235 . This is a "UBH & MEDICA" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 4G890CE 3G377LA SW . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".




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