Provider Demographics
NPI:1912436833
Name:WESLEY, STARLA MARIE (LADC)
Entity Type:Individual
Prefix:
First Name:STARLA
Middle Name:MARIE
Last Name:WESLEY
Suffix:
Gender:F
Credentials:LADC
Other - Prefix:
Other - First Name:STARLA
Other - Middle Name:MARIE
Other - Last Name:MOORE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3300 COUNTY 10, SUITE 300 A
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN CENTER
Mailing Address - State:MN
Mailing Address - Zip Code:55429
Mailing Address - Country:US
Mailing Address - Phone:612-759-5654
Mailing Address - Fax:
Practice Address - Street 1:3300 COUNTY ROAD 10 STE 300A
Practice Address - Street 2:
Practice Address - City:BROOKLYN CENTER
Practice Address - State:MN
Practice Address - Zip Code:55429-3066
Practice Address - Country:US
Practice Address - Phone:612-759-5654
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-06-05
Last Update Date:2020-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
MN304663101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty