Provider Demographics
NPI:1184845265
Name:CARLSON, JULIA GAGE (LICSW)
Entity Type:Individual
Prefix:MRS
First Name:JULIA
Middle Name:GAGE
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 1:50 DAVIS AVE
Mailing Address - Street 2:
Mailing Address - City:BROOKLINE
Mailing Address - State:MA
Mailing Address - Zip Code:02445-7610
Mailing Address - Country:US
Mailing Address - Phone:617-232-5792
Mailing Address - Fax:
Practice Address - Street 1:66 CANAL ST
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02114-2002
Practice Address - Country:US
Practice Address - Phone:617-371-3040
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1140041041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA114004OtherLICSW