Provider Demographics
NPI:1386956464
Name:CARLSON, CARL SAMUEL (MS, LPES)
Entity type:Individual
Prefix:
First Name:CARL
Middle Name:SAMUEL
Last Name:CARLSON
Suffix:
Gender:M
Credentials:MS, LPES
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1171 MARKET ST
Mailing Address - Street 2:SUITE 103
Mailing Address - City:FORT MILL
Mailing Address - State:SC
Mailing Address - Zip Code:29708-6500
Mailing Address - Country:US
Mailing Address - Phone:704-641-8902
Mailing Address - Fax:
Practice Address - Street 1:1171 MARKET ST
Practice Address - Street 2:SUITE 103
Practice Address - City:FORT MILL
Practice Address - State:SC
Practice Address - Zip Code:29708-6500
Practice Address - Country:US
Practice Address - Phone:704-641-8902
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-07-06
Last Update Date:2010-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC4579103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool