Provider Demographics
NPI:1366051344
Name:MAIN, CARRIE LOIS (MPS, LADC, LPCC)
Entity type:Individual
Prefix:
First Name:CARRIE
Middle Name:LOIS
Last Name:MAIN
Suffix:
Gender:F
Credentials:MPS, LADC, LPCC
Other - Prefix:
Other - First Name:CARRIE
Other - Middle Name:
Other - Last Name:SORESNON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1131 GOODVIEW AVE N
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55128-6129
Mailing Address - Country:US
Mailing Address - Phone:651-329-5041
Mailing Address - Fax:
Practice Address - Street 1:1811 WEIR DR STE 270
Practice Address - Street 2:
Practice Address - City:WOODBURY
Practice Address - State:MN
Practice Address - Zip Code:55125-6741
Practice Address - Country:US
Practice Address - Phone:651-714-9648
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-27
Last Update Date:2023-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN304951101YA0400X
MN2512101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Single Specialty