Provider Demographics
NPI:1437195641
Name:CARROLL-HANISCH, CHARLENE MARIE (MS LICSW)
Entity Type:Individual
Prefix:MS
First Name:CHARLENE
Middle Name:MARIE
Last Name:CARROLL-HANISCH
Suffix:
Gender:F
Credentials:MS LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1321 13TH ST N
Mailing Address - Street 2:
Mailing Address - City:ST CLOUD
Mailing Address - State:MN
Mailing Address - Zip Code:56303-2614
Mailing Address - Country:US
Mailing Address - Phone:320-252-5010
Mailing Address - Fax:320-203-1855
Practice Address - Street 1:1321 13TH ST N
Practice Address - Street 2:
Practice Address - City:ST CLOUD
Practice Address - State:MN
Practice Address - Zip Code:56303-2614
Practice Address - Country:US
Practice Address - Phone:320-252-5010
Practice Address - Fax:320-203-1855
Is Sole Proprietor?:No
Enumeration Date:2006-06-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN12147104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
151607C851OtherUCARE
6256246OtherMEDICA
49F67CAOtherBCBS
922241027913OtherPREFERRED ONE
MN796113800Medicaid
HP33738OtherHEALTH PARTNERS