Provider Demographics
NPI:1720329071
Name:CLOQUET PSYCHOLOGICAL LLC
Entity Type:Organization
Organization Name:CLOQUET PSYCHOLOGICAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LICENSED PSYCHOLOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:CAROLINE
Authorized Official - Middle Name:LOUISE
Authorized Official - Last Name:NELSON
Authorized Official - Suffix:
Authorized Official - Credentials:PSYDLP
Authorized Official - Phone:218-940-5259
Mailing Address - Street 1:605 KALLSTROM RD
Mailing Address - Street 2:
Mailing Address - City:CLOQUET
Mailing Address - State:MN
Mailing Address - Zip Code:55720-9415
Mailing Address - Country:US
Mailing Address - Phone:218-940-5259
Mailing Address - Fax:
Practice Address - Street 1:605 KALLSTROM RD
Practice Address - Street 2:
Practice Address - City:CLOQUET
Practice Address - State:MN
Practice Address - Zip Code:55720-9415
Practice Address - Country:US
Practice Address - Phone:218-940-5259
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-03-12
Last Update Date:2013-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP4209103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN417629400Medicaid
MN680001706OtherMEDICARE PTAN