Provider Demographics
NPI:1699085803
Name:GIANNONE, CAROLYN DAWN (PHD, LP)
Entity type:Individual
Prefix:
First Name:CAROLYN
Middle Name:DAWN
Last Name:GIANNONE
Suffix:
Gender:F
Credentials:PHD, LP
Other - Prefix:
Other - First Name:CAROLYN
Other - Middle Name:DAWN
Other - Last Name:TUDISCO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MS
Mailing Address - Street 1:1914 FAIRWAY LN NE
Mailing Address - Street 2:
Mailing Address - City:ALEXANDRIA
Mailing Address - State:MN
Mailing Address - Zip Code:56308-8611
Mailing Address - Country:US
Mailing Address - Phone:320-762-2400
Mailing Address - Fax:320-762-8047
Practice Address - Street 1:1500 IRVING ST
Practice Address - Street 2:
Practice Address - City:ALEXANDRIA
Practice Address - State:MN
Practice Address - Zip Code:56308-2515
Practice Address - Country:US
Practice Address - Phone:320-762-2400
Practice Address - Fax:320-762-8047
Is Sole Proprietor?:No
Enumeration Date:2010-10-21
Last Update Date:2015-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
MN5627103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program