Provider Demographics
NPI:1881816353
Name:CARR-HERSETH, JANICE G (LICSW)
Entity Type:Individual
Prefix:
First Name:JANICE
Middle Name:G
Last Name:CARR-HERSETH
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:JANICE
Other - Middle Name:G
Other - Last Name:CARR
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LICSW
Mailing Address - Street 1:715 DELMORE DR
Mailing Address - Street 2:
Mailing Address - City:ROSEAU
Mailing Address - State:MN
Mailing Address - Zip Code:56751-1534
Mailing Address - Country:US
Mailing Address - Phone:218-463-2500
Mailing Address - Fax:218-463-4782
Practice Address - Street 1:715 DELMORE DR
Practice Address - Street 2:
Practice Address - City:ROSEAU
Practice Address - State:MN
Practice Address - Zip Code:56751-1534
Practice Address - Country:US
Practice Address - Phone:218-463-2500
Practice Address - Fax:218-463-4782
Is Sole Proprietor?:No
Enumeration Date:2007-05-03
Last Update Date:2019-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN9295101YM0800X, 104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN497472700Medicaid