Provider Demographics
NPI:1124631171
Name:CARLSON, MARISSA (LCSW)
Entity type:Individual
Prefix:
First Name:MARISSA
Middle Name:
Last Name:CARLSON
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13498 E LAY LN
Mailing Address - Street 2:
Mailing Address - City:MEDIMONT
Mailing Address - State:ID
Mailing Address - Zip Code:83842-9775
Mailing Address - Country:US
Mailing Address - Phone:208-582-4024
Mailing Address - Fax:208-717-9450
Practice Address - Street 1:201 N 8TH ST STE 4
Practice Address - Street 2:
Practice Address - City:SAINT MARIES
Practice Address - State:ID
Practice Address - Zip Code:83861-1869
Practice Address - Country:US
Practice Address - Phone:208-597-7639
Practice Address - Fax:208-717-9450
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-28
Last Update Date:2024-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID39959104100000X
IDLCSW-43558104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID39959OtherLICENSE