Provider Demographics
NPI:1992036875
Name:CARLSON, MARK
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:CARLSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2910 FRANKS RD
Mailing Address - Street 2:
Mailing Address - City:HUNTINGDON VALLEY
Mailing Address - State:PA
Mailing Address - Zip Code:19006-4255
Mailing Address - Country:US
Mailing Address - Phone:215-478-1844
Mailing Address - Fax:215-938-7607
Practice Address - Street 1:2910 FRANKS RD
Practice Address - Street 2:
Practice Address - City:HUNTINGDON VALLEY
Practice Address - State:PA
Practice Address - Zip Code:19006-4255
Practice Address - Country:US
Practice Address - Phone:215-478-1844
Practice Address - Fax:215-938-7607
Is Sole Proprietor?:Yes
Enumeration Date:2010-01-16
Last Update Date:2010-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMF000073106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist