Provider Demographics
NPI:1073280590
Name:CARLSON, ANDREA MELLEN (MSW, CSW)
Entity Type:Individual
Prefix:MRS
First Name:ANDREA
Middle Name:MELLEN
Last Name:CARLSON
Suffix:
Gender:F
Credentials:MSW, CSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:562 W PACIFIC DR
Mailing Address - Street 2:
Mailing Address - City:AMERICAN FORK
Mailing Address - State:UT
Mailing Address - Zip Code:84003-1406
Mailing Address - Country:US
Mailing Address - Phone:801-477-4084
Mailing Address - Fax:
Practice Address - Street 1:562 W PACIFIC DR
Practice Address - Street 2:
Practice Address - City:AMERICAN FORK
Practice Address - State:UT
Practice Address - Zip Code:84003-1406
Practice Address - Country:US
Practice Address - Phone:801-477-4084
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-23
Last Update Date:2021-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT11767362-3502101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health