Provider Demographics
NPI:1063022879
Name:CARLSON, TONYA JOY
Entity Type:Individual
Prefix:
First Name:TONYA
Middle Name:JOY
Last Name:CARLSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:348 PARKWAY S
Mailing Address - Street 2:
Mailing Address - City:BREWER
Mailing Address - State:ME
Mailing Address - Zip Code:04412-1720
Mailing Address - Country:US
Mailing Address - Phone:207-951-0634
Mailing Address - Fax:
Practice Address - Street 1:49 FLORIDA AVE
Practice Address - Street 2:
Practice Address - City:BANGOR
Practice Address - State:ME
Practice Address - Zip Code:04401-3005
Practice Address - Country:US
Practice Address - Phone:207-299-1414
Practice Address - Fax:207-947-6278
Is Sole Proprietor?:No
Enumeration Date:2020-08-06
Last Update Date:2020-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEMC188411041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical