Provider Demographics
NPI:1962879122
Name:CARLSON, ERIC B (LMFT)
Entity type:Individual
Prefix:MR
First Name:ERIC
Middle Name:B
Last Name:CARLSON
Suffix:
Gender:M
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4551 GLENCOE AVE STE 255
Mailing Address - Street 2:
Mailing Address - City:MARINA DEL REY
Mailing Address - State:CA
Mailing Address - Zip Code:90292-7924
Mailing Address - Country:US
Mailing Address - Phone:310-572-7000
Mailing Address - Fax:310-943-2293
Practice Address - Street 1:4551 GLENCOE AVE STE 255
Practice Address - Street 2:
Practice Address - City:MARINA DEL REY
Practice Address - State:CA
Practice Address - Zip Code:90292-7924
Practice Address - Country:US
Practice Address - Phone:310-572-7000
Practice Address - Fax:310-943-2293
Is Sole Proprietor?:Yes
Enumeration Date:2015-08-24
Last Update Date:2020-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAIMF79358106H00000X
CALMFT96974106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist