Provider Demographics
NPI:1063599637
Name:CARLSON, JUDITH KAREN (MD)
Entity type:Individual
Prefix:
First Name:JUDITH
Middle Name:KAREN
Last Name:CARLSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:55 WEST MAIN STREET SUITE 410
Mailing Address - Street 2:WESTERN CONNECTICUT MENTAL HEALTH NETWORK
Mailing Address - City:WATERBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06702
Mailing Address - Country:US
Mailing Address - Phone:203-805-6408
Mailing Address - Fax:203-805-6432
Practice Address - Street 1:55 WEST MAIN STREET SUITE 410
Practice Address - Street 2:WESTERN CONNECTICUT MENTAL HEALTH NETWORK
Practice Address - City:WATERBURY
Practice Address - State:CT
Practice Address - Zip Code:06702
Practice Address - Country:US
Practice Address - Phone:203-805-6408
Practice Address - Fax:203-805-6432
Is Sole Proprietor?:No
Enumeration Date:2006-11-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0282602084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
ES2541Medicare UPIN