Provider Demographics
NPI:1093247561
Name:CARLSON, HEATHER LYNN (MA, LPC)
Entity Type:Individual
Prefix:MRS
First Name:HEATHER
Middle Name:LYNN
Last Name:CARLSON
Suffix:
Gender:F
Credentials:MA, LPC
Other - Prefix:MS
Other - First Name:HEATHER
Other - Middle Name:LYNN
Other - Last Name:BICKLER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MA, LPC
Mailing Address - Street 1:121 W MAIN ST
Mailing Address - Street 2:P.O. BOX 994
Mailing Address - City:PORT WASHINGTON
Mailing Address - State:WI
Mailing Address - Zip Code:53074-1813
Mailing Address - Country:US
Mailing Address - Phone:262-284-8229
Mailing Address - Fax:262-284-8104
Practice Address - Street 1:121 W MAIN ST
Practice Address - Street 2:
Practice Address - City:PORT WASHINGTON
Practice Address - State:WI
Practice Address - Zip Code:53074-1813
Practice Address - Country:US
Practice Address - Phone:262-284-8229
Practice Address - Fax:262-284-8104
Is Sole Proprietor?:No
Enumeration Date:2017-04-03
Last Update Date:2017-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3765-125101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional