Provider Demographics
NPI:1114204724
Name:CARLSON, DUANE M (LADC)
Entity Type:Individual
Prefix:
First Name:DUANE
Middle Name:M
Last Name:CARLSON
Suffix:
Gender:M
Credentials:LADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7066 STILLWATER BLVD N
Mailing Address - Street 2:
Mailing Address - City:OAKDALE
Mailing Address - State:MN
Mailing Address - Zip Code:55128-3937
Mailing Address - Country:US
Mailing Address - Phone:651-777-5222
Mailing Address - Fax:651-251-5111
Practice Address - Street 1:375 ORLEANS ST E
Practice Address - Street 2:
Practice Address - City:STILLWATER
Practice Address - State:MN
Practice Address - Zip Code:55082-5830
Practice Address - Country:US
Practice Address - Phone:651-777-5222
Practice Address - Fax:651-251-5111
Is Sole Proprietor?:No
Enumeration Date:2011-11-10
Last Update Date:2011-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN303030101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)