Basic Information
| Provider Information | |||||||||
| NPI: | 1720052210 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GUEST | ||||||||
| FirstName: | CHARLOTTE | ||||||||
| MiddleName: | J | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1811 WEIR DR STE 355 | ||||||||
| Address2: | |||||||||
| City: | WOODBURY | ||||||||
| State: | MN | ||||||||
| PostalCode: | 551252273 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6512548580 | ||||||||
| FaxNumber: | 6517301700 | ||||||||
| Practice Location | |||||||||
| Address1: | 640 JACKSON ST | ||||||||
| Address2: | MAIL STOP 11303A | ||||||||
| City: | ST PAUL | ||||||||
| State: | MN | ||||||||
| PostalCode: | 551012502 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6512544786 | ||||||||
| FaxNumber: | 6512288362 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/14/2006 | ||||||||
| LastUpdateDate: | 05/20/2016 | ||||||||
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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 | 2084P0800X | 40941 | MN | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
ID Information
| ID | Type | State | Issuer | Description | 698318900 | 05 | MN | MEDICAID |