Provider Demographics
NPI:1164870374
Name:CARLSON, STEPHANIE
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:
Last Name:CARLSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:FRANKEE
Other - Middle Name:S
Other - Last Name:CARLSON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:2050 FAIRMONT DR
Mailing Address - Street 2:
Mailing Address - City:SAN LEANDRO
Mailing Address - State:CA
Mailing Address - Zip Code:94578-1001
Mailing Address - Country:US
Mailing Address - Phone:510-483-3030
Mailing Address - Fax:
Practice Address - Street 1:2050 FAIRMONT DR
Practice Address - Street 2:
Practice Address - City:SAN LEANDRO
Practice Address - State:CA
Practice Address - Zip Code:94578-1001
Practice Address - Country:US
Practice Address - Phone:510-483-3030
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-05-27
Last Update Date:2021-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA104457106H00000X, 106H00000X
CAAMFT104457106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist