Provider Demographics
NPI:1609450428
Name:ROLLO-CARLSON, CYNTHIA ANN (LICSW, LCSW,LADC)
Entity Type:Individual
Prefix:
First Name:CYNTHIA
Middle Name:ANN
Last Name:ROLLO-CARLSON
Suffix:
Gender:F
Credentials:LICSW, LCSW,LADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7561 FRONT ST NW
Mailing Address - Street 2:
Mailing Address - City:WALKER
Mailing Address - State:MN
Mailing Address - Zip Code:56484-2003
Mailing Address - Country:US
Mailing Address - Phone:808-345-3205
Mailing Address - Fax:
Practice Address - Street 1:1426 BEMIDJI AVE N STE 1
Practice Address - Street 2:
Practice Address - City:BEMIDJI
Practice Address - State:MN
Practice Address - Zip Code:56601-3882
Practice Address - Country:US
Practice Address - Phone:218-444-2233
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-07
Last Update Date:2023-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN301020101YA0400X
HILCSW-39111041C0700X
MN117041041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)