Provider Demographics
NPI:1568530020
Name:CERA, CAROLE GAIL (LICSW)
Entity Type:Individual
Prefix:
First Name:CAROLE
Middle Name:GAIL
Last Name:CERA
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5400 XERXES AVE S
Mailing Address - Street 2:
Mailing Address - City:EDINA
Mailing Address - State:MN
Mailing Address - Zip Code:55410-2457
Mailing Address - Country:US
Mailing Address - Phone:952-924-4932
Mailing Address - Fax:
Practice Address - Street 1:13100 WAYZATA BLVD
Practice Address - Street 2:SUITE 400
Practice Address - City:MINNETONKA
Practice Address - State:MN
Practice Address - Zip Code:55305-1802
Practice Address - Country:US
Practice Address - Phone:952-546-0616
Practice Address - Fax:952-573-1778
Is Sole Proprietor?:No
Enumeration Date:2006-12-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN045151041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN793557900OtherMEDICAL ASSISTANCE
MN6220235OtherUBH & MEDICA
MN4G890CE 3G377LA SWOtherBLUE CROSS BLUE SHIELD
MN800000532 C01878Medicare ID - Type Unspecified