Provider Demographics
NPI:1801515002
Name:PHILLIPS, CARRIE ANN (LADC)
Entity type:Individual
Prefix:
First Name:CARRIE
Middle Name:ANN
Last Name:PHILLIPS
Suffix:
Gender:F
Credentials:LADC
Other - Prefix:
Other - First Name:CARRIE
Other - Middle Name:ANN
Other - Last Name:MACINTOSH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1223 MAYWOOD ST
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55117-4133
Mailing Address - Country:US
Mailing Address - Phone:612-759-5742
Mailing Address - Fax:
Practice Address - Street 1:831 COMMONWEALTH AVE
Practice Address - Street 2:
Practice Address - City:DULUTH
Practice Address - State:MN
Practice Address - Zip Code:55808-1913
Practice Address - Country:US
Practice Address - Phone:612-759-5742
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-08-23
Last Update Date:2022-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN306462101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)