Provider Demographics
NPI:1194185728
Name:BECKER, CARLYN
Entity Type:Individual
Prefix:
First Name:CARLYN
Middle Name:
Last Name:BECKER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25210 HAZELWOOD DR
Mailing Address - Street 2:
Mailing Address - City:NISSWA
Mailing Address - State:MN
Mailing Address - Zip Code:56468-2797
Mailing Address - Country:US
Mailing Address - Phone:763-438-4619
Mailing Address - Fax:
Practice Address - Street 1:25210 HAZELWOOD DR
Practice Address - Street 2:
Practice Address - City:NISSWA
Practice Address - State:MN
Practice Address - Zip Code:56468-2797
Practice Address - Country:US
Practice Address - Phone:763-438-4619
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-02-24
Last Update Date:2023-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN303742101YA0400X
MNCC01826101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)