Provider Demographics
NPI:1154486603
Name:CARLSON, PHYLLIS WIDBUR (LICSW)
Entity Type:Individual
Prefix:
First Name:PHYLLIS
Middle Name:WIDBUR
Last Name:CARLSON
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15 RAVENNA RD
Mailing Address - Street 2:
Mailing Address - City:ROSLINDALE
Mailing Address - State:MA
Mailing Address - Zip Code:02131
Mailing Address - Country:US
Mailing Address - Phone:617-325-6759
Mailing Address - Fax:
Practice Address - Street 1:15 RAVENNA RD
Practice Address - Street 2:
Practice Address - City:ROSLINDALE
Practice Address - State:MA
Practice Address - Zip Code:02131
Practice Address - Country:US
Practice Address - Phone:617-325-6759
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA100299104100000X
MARN68987163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered104100000XBehavioral Health & Social Service ProvidersSocial Worker
Not Answered163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAA025829OtherPACIFICARE
MA16412OtherUBH
P01318Medicare UPIN
MAP01318Medicare ID - Type Unspecified