Provider Demographics
NPI:1962286690
Name:MANDERFELD, CARLY RAE (LGSW)
Entity type:Individual
Prefix:
First Name:CARLY
Middle Name:RAE
Last Name:MANDERFELD
Suffix:
Gender:F
Credentials:LGSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1241 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:MANKATO
Mailing Address - State:MN
Mailing Address - Zip Code:56001-5080
Mailing Address - Country:US
Mailing Address - Phone:507-217-0049
Mailing Address - Fax:
Practice Address - Street 1:7601 WAYZATA BLVD
Practice Address - Street 2:
Practice Address - City:ST LOUIS PARK
Practice Address - State:MN
Practice Address - Zip Code:55426-1623
Practice Address - Country:US
Practice Address - Phone:507-217-0049
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-23
Last Update Date:2023-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN32524101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor