Basic Information
| Provider Information | |||||||||
| NPI: | 1124376611 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PRIVATT | ||||||||
| FirstName: | CARMELITA | ||||||||
| MiddleName: | REGINA | ||||||||
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| Credential: | LPCC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1125 6TH ST SE | ||||||||
| Address2: | |||||||||
| City: | WILLMAR | ||||||||
| State: | MN | ||||||||
| PostalCode: | 562014675 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3202354613 | ||||||||
| FaxNumber: | 8556257406 | ||||||||
| Practice Location | |||||||||
| Address1: | 1125 6TH ST SE | ||||||||
| Address2: | |||||||||
| City: | WILLMAR | ||||||||
| State: | MN | ||||||||
| PostalCode: | 562014675 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3202354613 | ||||||||
| FaxNumber: | 8556257406 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/15/2012 | ||||||||
| LastUpdateDate: | 09/26/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101Y00000X | 907-7-15-17 | ND | N | Behavioral Health & Social Service Providers | Counselor | 101YP2500X | 1148 | MN | Y | Behavioral Health & Social Service Providers | Counselor | Professional |
No ID Information.