Provider Demographics
NPI:1083708150
Name:CARLSON, ROSE MARIE (PHD)
Entity Type:Individual
Prefix:
First Name:ROSE
Middle Name:MARIE
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 1:1545 W NORTHERN AVE
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85021-5453
Mailing Address - Country:US
Mailing Address - Phone:602-331-8200
Mailing Address - Fax:602-331-0755
Practice Address - Street 1:1545 W NORTHERN AVE
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85021-5453
Practice Address - Country:US
Practice Address - Phone:602-331-8200
Practice Address - Fax:602-331-0755
Is Sole Proprietor?:No
Enumeration Date:2006-10-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ854103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical