Provider Demographics
NPI:1700478625
Name:MCCORMACK, CARLY CRISTINE (LADC, LPCC)
Entity Type:Individual
Prefix:
First Name:CARLY
Middle Name:CRISTINE
Last Name:MCCORMACK
Suffix:
Gender:F
Credentials:LADC, LPCC
Other - Prefix:
Other - First Name:CARLY
Other - Middle Name:CRISTINE
Other - Last Name:RUTTER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1250 MOORE LAKE DR E STE 152
Mailing Address - Street 2:
Mailing Address - City:FRIDLEY
Mailing Address - State:MN
Mailing Address - Zip Code:55432-5135
Mailing Address - Country:US
Mailing Address - Phone:612-389-2332
Mailing Address - Fax:
Practice Address - Street 1:1250 MOORE LAKE DR E STE 152
Practice Address - Street 2:
Practice Address - City:FRIDLEY
Practice Address - State:MN
Practice Address - Zip Code:55432-5135
Practice Address - Country:US
Practice Address - Phone:612-389-2332
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-02-11
Last Update Date:2023-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN305956101YA0400X
MN3936101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)