Provider Demographics
NPI:1457408551
Name:FELTY, CAROLYN MERRILL (MA LP)
Entity Type:Individual
Prefix:
First Name:CAROLYN
Middle Name:MERRILL
Last Name:FELTY
Suffix:
Gender:F
Credentials:MA LP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7066 STILLWATER BLVD N
Mailing Address - Street 2:
Mailing Address - City:OAKDALE
Mailing Address - State:MN
Mailing Address - Zip Code:55128-3937
Mailing Address - Country:US
Mailing Address - Phone:651-777-5222
Mailing Address - Fax:612-728-5301
Practice Address - Street 1:7066 STILLWATER BLVD N
Practice Address - Street 2:
Practice Address - City:OAKDALE
Practice Address - State:MN
Practice Address - Zip Code:55128-3937
Practice Address - Country:US
Practice Address - Phone:651-777-5222
Practice Address - Fax:612-728-5301
Is Sole Proprietor?:No
Enumeration Date:2007-01-04
Last Update Date:2020-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP5108103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist