Provider Demographics
NPI:1235157397
Name:WEISS, CAROLINE NICOLE (PSYD, LP)
Entity type:Individual
Prefix:
First Name:CAROLINE
Middle Name:NICOLE
Last Name:WEISS
Suffix:
Gender:F
Credentials:PSYD, LP
Other - Prefix:
Other - First Name:CAROLINE
Other - Middle Name:NICOLE
Other - Last Name:JACK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 43
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55440-0043
Mailing Address - Country:US
Mailing Address - Phone:612-262-1166
Mailing Address - Fax:612-262-9035
Practice Address - Street 1:10705 TOWN SQUARE DR NE STE 100
Practice Address - Street 2:
Practice Address - City:BLAINE
Practice Address - State:MN
Practice Address - Zip Code:55449-8185
Practice Address - Country:US
Practice Address - Phone:763-236-5400
Practice Address - Fax:763-236-5350
Is Sole Proprietor?:No
Enumeration Date:2006-07-17
Last Update Date:2024-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP4614103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN410640700Medicaid
MN680002048Medicare Oscar/Certification