1518574672 NPI number — CAROL SUSAN ELSTAD LPCC

Table of content: CAROL SUSAN ELSTAD LPCC (NPI 1518574672)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1518574672 NPI number — CAROL SUSAN ELSTAD LPCC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ELSTAD
Provider First Name:
CAROL
Provider Middle Name:
SUSAN
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
LPCC
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:
1518574672
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/23/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
13764 APOLLO WAY
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ROSEMOUNT
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55068-2171
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
612-845-4112
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
MN MENTAL HEALTH CLINICS
Provider Second Line Business Practice Location Address:
15160 FOLIAGE AVE SUITE 140
Provider Business Practice Location Address City Name:
APPLE VALLEY
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55124
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
651-365-8251
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
09/23/2020

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: 101YM0800X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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