Provider Demographics
NPI:1346269602
Name:CARR, THERESA MARIE (RN, CNS)
Entity Type:Individual
Prefix:
First Name:THERESA
Middle Name:MARIE
Last Name:CARR
Suffix:
Gender:F
Credentials:RN, CNS
Other - Prefix:
Other - First Name:THERESA
Other - Middle Name:MARIE
Other - Last Name:HORVAT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1900 SILVER LAKE RD NW
Mailing Address - Street 2:SUITE 110
Mailing Address - City:NEW BRIGHTON
Mailing Address - State:MN
Mailing Address - Zip Code:55112-1786
Mailing Address - Country:US
Mailing Address - Phone:651-628-9566
Mailing Address - Fax:
Practice Address - Street 1:332 W SUPERIOR ST
Practice Address - Street 2:SUITE 300
Practice Address - City:DULUTH
Practice Address - State:MN
Practice Address - Zip Code:55802-1808
Practice Address - Country:US
Practice Address - Phone:218-722-4379
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-18
Last Update Date:2017-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNCNS0322363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN953172600Medicaid
MN890000365Medicare PIN
MN890000367Medicare PIN
MN890000362Medicare PIN
MNQ32200Medicare UPIN
MN953172600Medicaid