Provider Demographics
NPI:1396566683
Name:CARLSON, AMELIA MARJORIE
Entity type:Individual
Prefix:
First Name:AMELIA
Middle Name:MARJORIE
Last Name:CARLSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:500 CRAIG RD STE 102
Mailing Address - Street 2:
Mailing Address - City:MANALAPAN
Mailing Address - State:NJ
Mailing Address - Zip Code:07726-8748
Mailing Address - Country:US
Mailing Address - Phone:732-982-2888
Mailing Address - Fax:
Practice Address - Street 1:500 CRAIG RD STE 102
Practice Address - Street 2:
Practice Address - City:MANALAPAN
Practice Address - State:NJ
Practice Address - Zip Code:07726-8748
Practice Address - Country:US
Practice Address - Phone:732-982-2888
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-10-21
Last Update Date:2024-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ37AC00786000101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health