Provider Demographics
NPI:1699097063
Name:THEODORE, CARLSON ANDREWS (LCMHC)
Entity type:Individual
Prefix:MR
First Name:CARLSON
Middle Name:ANDREWS
Last Name:THEODORE
Suffix:
Gender:M
Credentials:LCMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:96 ELDERBERRY LN
Mailing Address - Street 2:
Mailing Address - City:ROUGEMONT
Mailing Address - State:NC
Mailing Address - Zip Code:27572-9275
Mailing Address - Country:US
Mailing Address - Phone:919-240-9192
Mailing Address - Fax:
Practice Address - Street 1:96 ELDERBERRY LN
Practice Address - Street 2:
Practice Address - City:ROUGEMONT
Practice Address - State:NC
Practice Address - Zip Code:27572-9275
Practice Address - Country:US
Practice Address - Phone:919-240-9192
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-02-25
Last Update Date:2023-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC7744101YM0800X, 101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7744OtherNORTH CAROLINA BOARD OF LICENSED CLINICAL MENTAL HEALTH COUNSELORS