Provider Demographics
NPI:1346476009
Name:CARLON, SALLY (LPCC)
Entity type:Individual
Prefix:
First Name:SALLY
Middle Name:
Last Name:CARLON
Suffix:
Gender:F
Credentials:LPCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9217 GALAXIA WAY NE
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87111
Mailing Address - Country:US
Mailing Address - Phone:505-681-3819
Mailing Address - Fax:505-888-1686
Practice Address - Street 1:3901 LOUISIANA BLVD NE
Practice Address - Street 2:SUITE C
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87110-1577
Practice Address - Country:US
Practice Address - Phone:505-888-1686
Practice Address - Fax:505-888-1683
Is Sole Proprietor?:Yes
Enumeration Date:2009-06-08
Last Update Date:2017-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM0154131101YP2500X, 101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM65704266Medicaid