Provider Demographics
NPI:1104977271
Name:CARLSON, DIANE A (MFT)
Entity type:Individual
Prefix:DR
First Name:DIANE
Middle Name:A
Last Name:CARLSON
Suffix:
Gender:F
Credentials:MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2525 VIA PISA
Mailing Address - Street 2:
Mailing Address - City:DEL MAR
Mailing Address - State:CA
Mailing Address - Zip Code:92014
Mailing Address - Country:US
Mailing Address - Phone:858-847-0638
Mailing Address - Fax:
Practice Address - Street 1:2525 VIA PISA
Practice Address - Street 2:
Practice Address - City:DEL MAR
Practice Address - State:CA
Practice Address - Zip Code:92014-3815
Practice Address - Country:US
Practice Address - Phone:858-847-0638
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFT21255101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health