Provider Demographics
NPI:1427556240
Name:CARLSON, NICOLE (LCSW, PMHNP-BC)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:CARLSON
Suffix:
Gender:F
Credentials:LCSW, PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2600 E SOUTHERN AVE STE C3
Mailing Address - Street 2:
Mailing Address - City:TEMPE
Mailing Address - State:AZ
Mailing Address - Zip Code:85282-7609
Mailing Address - Country:US
Mailing Address - Phone:626-515-8875
Mailing Address - Fax:480-879-3048
Practice Address - Street 1:2600 E SOUTHERN AVE STE C3
Practice Address - Street 2:
Practice Address - City:TEMPE
Practice Address - State:AZ
Practice Address - Zip Code:85282-7609
Practice Address - Country:US
Practice Address - Phone:626-515-8875
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-01-26
Last Update Date:2024-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLCSW-199861041C0700X
AZ276452163W00000X, 363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No163W00000XNursing Service ProvidersRegistered Nurse