Provider Demographics
NPI:1699148510
Name:CARLSON, MELINDA BLAIRE (LCSWA)
Entity type:Individual
Prefix:
First Name:MELINDA
Middle Name:BLAIRE
Last Name:CARLSON
Suffix:
Gender:F
Credentials:LCSWA
Other - Prefix:
Other - First Name:MELINDA
Other - Middle Name:BLAIRE
Other - Last Name:JOHNSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4300 SAPPHIRE CT STE 110
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27834-9079
Mailing Address - Country:US
Mailing Address - Phone:252-830-7561
Mailing Address - Fax:252-413-0932
Practice Address - Street 1:3408 WILSHIRE BLVD
Practice Address - Street 2:SUITE 100
Practice Address - City:WILMINGTON
Practice Address - State:NC
Practice Address - Zip Code:28403-4339
Practice Address - Country:US
Practice Address - Phone:910-251-5326
Practice Address - Fax:910-632-2355
Is Sole Proprietor?:No
Enumeration Date:2015-11-02
Last Update Date:2015-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCP0101261041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical