Provider Demographics
NPI:1356386023
Name:PHELPS, CAROLYN F (PHD, LP)
Entity type:Individual
Prefix:
First Name:CAROLYN
Middle Name:F
Last Name:PHELPS
Suffix:
Gender:F
Credentials:PHD, LP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
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:218-606-1844
Mailing Address - Fax:218-606-1855
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:218-606-1844
Practice Address - Fax:218-606-1855
Is Sole Proprietor?:No
Enumeration Date:2006-06-18
Last Update Date:2022-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP3015103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN758015100Medicaid
MN758015100Medicaid