Provider Demographics
NPI:1255094728
Name:CARLSON, HEATHER JANE (MA, MFTC)
Entity Type:Individual
Prefix:
First Name:HEATHER
Middle Name:JANE
Last Name:CARLSON
Suffix:
Gender:F
Credentials:MA, MFTC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2305 CANYON BLVD STE 101
Mailing Address - Street 2:
Mailing Address - City:BOULDER
Mailing Address - State:CO
Mailing Address - Zip Code:80302-5651
Mailing Address - Country:US
Mailing Address - Phone:704-488-8077
Mailing Address - Fax:
Practice Address - Street 1:2305 CANYON BLVD STE 101
Practice Address - Street 2:
Practice Address - City:BOULDER
Practice Address - State:CO
Practice Address - Zip Code:80302-5651
Practice Address - Country:US
Practice Address - Phone:704-488-8077
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-20
Last Update Date:2024-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106H00000X
COMFTC.0014218106H00000X
COMFT.0002512106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist