Provider Demographics
NPI:1265080501
Name:NIESCHE, CAROLYN J
Entity type:Individual
Prefix:MS
First Name:CAROLYN
Middle Name:J
Last Name:NIESCHE
Suffix:
Gender:F
Credentials:
Other - Prefix:MR
Other - First Name:PAUL
Other - Middle Name:MARK
Other - Last Name:BIERCH
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:CPRC
Mailing Address - Street 1:2520 N 2ND ST
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55411-2200
Mailing Address - Country:US
Mailing Address - Phone:612-521-4178
Mailing Address - Fax:
Practice Address - Street 1:2520 N 2ND ST
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55411-2200
Practice Address - Country:US
Practice Address - Phone:612-521-4178
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-29
Last Update Date:2021-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN175T00000XMedicaid