Provider Demographics
NPI:1427295138
Name:CARSON, CODY (PHD)
Entity type:Individual
Prefix:
First Name:CODY
Middle Name:
Last Name:CARSON
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1333 MOURSUND ST
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77030-3405
Mailing Address - Country:US
Mailing Address - Phone:713-797-7761
Mailing Address - Fax:713-799-7049
Practice Address - Street 1:1333 MOURSUND ST
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77030-3405
Practice Address - Country:US
Practice Address - Phone:713-797-7761
Practice Address - Fax:713-799-7049
Is Sole Proprietor?:No
Enumeration Date:2009-01-16
Last Update Date:2016-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX36808103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY30610026Medicaid