Provider Demographics
NPI:1487905410
Name:CARLSON, MARTA L (PHD)
Entity type:Individual
Prefix:
First Name:MARTA
Middle Name:L
Last Name:CARLSON
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 PLEASANT ST
Mailing Address - Street 2:
Mailing Address - City:PAXTON
Mailing Address - State:MA
Mailing Address - Zip Code:01612-1564
Mailing Address - Country:US
Mailing Address - Phone:774-239-1706
Mailing Address - Fax:
Practice Address - Street 1:100 GROVE ST
Practice Address - Street 2:SUITE 307
Practice Address - City:WORCESTER
Practice Address - State:MA
Practice Address - Zip Code:01605-2627
Practice Address - Country:US
Practice Address - Phone:774-239-1706
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-10-01
Last Update Date:2012-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA3884101YM0800X
RIPS00667103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No103T00000XBehavioral Health & Social Service ProvidersPsychologist