Basic Information
| Provider Information | |||||||||
| NPI: | 1346269602 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CARR | ||||||||
| FirstName: | THERESA | ||||||||
| MiddleName: | MARIE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | RN, CNS | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | HORVAT | ||||||||
| OtherFirstName: | THERESA | ||||||||
| OtherMiddleName: | MARIE | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1900 SILVER LAKE RD NW | ||||||||
| Address2: | SUITE 110 | ||||||||
| City: | NEW BRIGHTON | ||||||||
| State: | MN | ||||||||
| PostalCode: | 551121786 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6516289566 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 332 W SUPERIOR ST | ||||||||
| Address2: | SUITE 300 | ||||||||
| City: | DULUTH | ||||||||
| State: | MN | ||||||||
| PostalCode: | 558021808 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2187224379 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/18/2006 | ||||||||
| LastUpdateDate: | 02/27/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LP0808X | CNS0322 | MN | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Psych/Mental Health |
ID Information
| ID | Type | State | Issuer | Description | 953172600 | 05 | MN | MEDICAID |