Provider Demographics
NPI:1427197094
Name:KNUDTSON, CAROL R (MED, LPC)
Entity type:Individual
Prefix:MS
First Name:CAROL
Middle Name:R
Last Name:KNUDTSON
Suffix:
Gender:F
Credentials:MED, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3204 S. MOONFLOWER AVE.
Mailing Address - Street 2:
Mailing Address - City:SIOUX FALLS
Mailing Address - State:SD
Mailing Address - Zip Code:57110-4414
Mailing Address - Country:US
Mailing Address - Phone:605-271-6416
Mailing Address - Fax:605-271-2782
Practice Address - Street 1:3204 S. MOONFLOWER AVE.
Practice Address - Street 2:
Practice Address - City:SIOUX FALLS
Practice Address - State:SD
Practice Address - Zip Code:57110-4414
Practice Address - Country:US
Practice Address - Phone:605-271-6416
Practice Address - Fax:605-271-2782
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-06
Last Update Date:2012-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SDSD 604101Y00000X
SD#604101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor