Provider Demographics
NPI:1235456146
Name:CARLSON, LYNNETTE (LMHC)
Entity Type:Individual
Prefix:
First Name:LYNNETTE
Middle Name:
Last Name:CARLSON
Suffix:
Gender:F
Credentials:LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1319 W BLOOMFIELD RD
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IN
Mailing Address - Zip Code:47403-2000
Mailing Address - Country:US
Mailing Address - Phone:812-331-1235
Mailing Address - Fax:812-353-6137
Practice Address - Street 1:1319 W BLOOMFIELD RD
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IN
Practice Address - Zip Code:47403-2000
Practice Address - Country:US
Practice Address - Phone:812-331-1235
Practice Address - Fax:812-353-6137
Is Sole Proprietor?:No
Enumeration Date:2010-05-02
Last Update Date:2010-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN39000586A101YP1600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP1600XBehavioral Health & Social Service ProvidersCounselorPastoral
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000545373OtherANTHEM NON-PAR PIN NUMBER