Provider Demographics
NPI:1124323795
Name:CARLSON, TINA MARIE (LPC)
Entity type:Individual
Prefix:
First Name:TINA
Middle Name:MARIE
Last Name:CARLSON
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2672 NORWICH ST
Mailing Address - Street 2:
Mailing Address - City:FITCHBURG
Mailing Address - State:WI
Mailing Address - Zip Code:53711-5456
Mailing Address - Country:US
Mailing Address - Phone:715-919-0832
Mailing Address - Fax:
Practice Address - Street 1:3579 SIGGELKOW RD
Practice Address - Street 2:
Practice Address - City:MC FARLAND
Practice Address - State:WI
Practice Address - Zip Code:53558-9646
Practice Address - Country:US
Practice Address - Phone:608-838-8999
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-01-12
Last Update Date:2011-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI125-3308101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional