Provider Demographics
NPI:1205866472
Name:CARLSON, KENNETH M (PHD)
Entity Type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:M
Last Name:CARLSON
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2808 17TH AVE S
Mailing Address - Street 2:
Mailing Address - City:GRAND FORKS
Mailing Address - State:ND
Mailing Address - Zip Code:58201-4010
Mailing Address - Country:US
Mailing Address - Phone:701-746-8376
Mailing Address - Fax:701-746-9872
Practice Address - Street 1:2808 17TH AVE S
Practice Address - Street 2:
Practice Address - City:GRAND FORKS
Practice Address - State:ND
Practice Address - Zip Code:58201-4010
Practice Address - Country:US
Practice Address - Phone:701-746-8376
Practice Address - Fax:701-746-9872
Is Sole Proprietor?:No
Enumeration Date:2006-07-04
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND80103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND16926Medicaid
ND16926Medicaid
NDR02212Medicare UPIN