Provider Demographics
NPI:1912145517
Name:CARLSON, PHYLLIS ANNE (PHD)
Entity type:Individual
Prefix:DR
First Name:PHYLLIS
Middle Name:ANNE
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 1:5 LEIGHTON COURT
Mailing Address - Street 2:
Mailing Address - City:MELVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:11747
Mailing Address - Country:US
Mailing Address - Phone:631-495-7254
Mailing Address - Fax:
Practice Address - Street 1:5 LEIGHTON CT
Practice Address - Street 2:
Practice Address - City:MELVILLE
Practice Address - State:NY
Practice Address - Zip Code:11747-3910
Practice Address - Country:US
Practice Address - Phone:631-495-7254
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-02-04
Last Update Date:2009-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY5724103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical