Provider Demographics
NPI:1063918647
Name:CARLSON, GEORGETTA RENEE (MSW)
Entity type:Individual
Prefix:
First Name:GEORGETTA
Middle Name:RENEE
Last Name:CARLSON
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:630 HAINES AVE NW
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87102-1226
Mailing Address - Country:US
Mailing Address - Phone:505-268-5611
Mailing Address - Fax:
Practice Address - Street 1:1201 3RD ST NW
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87102-1403
Practice Address - Country:US
Practice Address - Phone:505-764-8231
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-04-03
Last Update Date:2023-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMX-10429104100000X
NM1616175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist
No104100000XBehavioral Health & Social Service ProvidersSocial Worker