Provider Demographics
NPI:1083907497
Name:TELLETT, CAROL RUTH (LP)
Entity Type:Individual
Prefix:MS
First Name:CAROL
Middle Name:RUTH
Last Name:TELLETT
Suffix:
Gender:F
Credentials:LP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8700 W 36TH ST
Mailing Address - Street 2:SUITE #214
Mailing Address - City:ST LOUIS PARK
Mailing Address - State:MN
Mailing Address - Zip Code:55426-3906
Mailing Address - Country:US
Mailing Address - Phone:952-484-4309
Mailing Address - Fax:952-922-0845
Practice Address - Street 1:8700 W 36TH ST
Practice Address - Street 2:SUITE #214
Practice Address - City:ST LOUIS PARK
Practice Address - State:MN
Practice Address - Zip Code:55426-3906
Practice Address - Country:US
Practice Address - Phone:952-484-4309
Practice Address - Fax:952-922-0845
Is Sole Proprietor?:Yes
Enumeration Date:2011-05-17
Last Update Date:2014-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP2572103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist