Provider Demographics
NPI:1144472853
Name:MECKLENBURG, CAROL ELAINE (PHD LP)
Entity type:Individual
Prefix:
First Name:CAROL
Middle Name:ELAINE
Last Name:MECKLENBURG
Suffix:
Gender:F
Credentials:PHD LP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:707 HAMLINE AVE S
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55116-2238
Mailing Address - Country:US
Mailing Address - Phone:651-431-0305
Mailing Address - Fax:
Practice Address - Street 1:2399 ARIEL ST N STE D
Practice Address - Street 2:
Practice Address - City:MAPLEWOOD
Practice Address - State:MN
Practice Address - Zip Code:55109-2202
Practice Address - Country:US
Practice Address - Phone:651-770-1311
Practice Address - Fax:651-770-1879
Is Sole Proprietor?:Yes
Enumeration Date:2008-10-14
Last Update Date:2008-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN4962103TC2200X
MN254940103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent
No103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool