Basic Information
| Provider Information | |||||||||
| NPI: | 1598198152 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CLEARY | ||||||||
| FirstName: | DARLA | ||||||||
| MiddleName: | |||||||||
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| Credential: | MA, LPCC | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | DRENTLAW | ||||||||
| OtherFirstName: | DARLA | ||||||||
| OtherMiddleName: | |||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 5868 BAKER RD | ||||||||
| Address2: | |||||||||
| City: | MINNETONKA | ||||||||
| State: | MN | ||||||||
| PostalCode: | 553455903 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 5868 BAKER RD | ||||||||
| Address2: | |||||||||
| City: | MINNETONKA | ||||||||
| State: | MN | ||||||||
| PostalCode: | 553455903 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9527674200 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/18/2013 | ||||||||
| LastUpdateDate: | 06/06/2019 | ||||||||
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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 | 101YM0800X | C.1200183 | OH | N | Behavioral Health & Social Service Providers | Counselor | Mental Health | 101YP2500X | 2146 | MN | Y | Behavioral Health & Social Service Providers | Counselor | Professional |
No ID Information.