Provider Demographics
NPI:1013508951
Name:WIGER, CAROLYN R (LADC)
Entity Type:Individual
Prefix:
First Name:CAROLYN
Middle Name:R
Last Name:WIGER
Suffix:
Gender:F
Credentials:LADC
Other - Prefix:
Other - First Name:CAROLYN
Other - Middle Name:
Other - Last Name:WIGER
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:14949 62ND ST N
Mailing Address - Street 2:
Mailing Address - City:STILLWATER
Mailing Address - State:MN
Mailing Address - Zip Code:55082-6132
Mailing Address - Country:US
Mailing Address - Phone:651-430-6460
Mailing Address - Fax:
Practice Address - Street 1:14949 62ND ST N
Practice Address - Street 2:
Practice Address - City:STILLWATER
Practice Address - State:MN
Practice Address - Zip Code:55082-6132
Practice Address - Country:US
Practice Address - Phone:651-430-6460
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-02-02
Last Update Date:2021-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN303293101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)