Provider Demographics
NPI:1710467071
Name:CAROLYN PHELPS PHDLP LLC
Entity Type:Organization
Organization Name:CAROLYN PHELPS PHDLP LLC
Other - Org Name:DREAMLIFE PSYCHOLOGICAL SERVICES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PSYCHOLOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:CAROLYN
Authorized Official - Middle Name:
Authorized Official - Last Name:PHELPS
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:218-341-2834
Mailing Address - Street 1:302 W SUPERIOR ST STE 502
Mailing Address - Street 2:
Mailing Address - City:DULUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55802-5115
Mailing Address - Country:US
Mailing Address - Phone:218-341-2834
Mailing Address - Fax:
Practice Address - Street 1:302 W SUPERIOR ST STE 502
Practice Address - Street 2:
Practice Address - City:DULUTH
Practice Address - State:MN
Practice Address - Zip Code:55802-5115
Practice Address - Country:US
Practice Address - Phone:218-341-2834
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-08-16
Last Update Date:2018-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP3015261QM0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)