Provider Demographics
NPI:1265661243
Name:CARLSON, MARK FREDERICK (MS, CCC-SLP)
Entity Type:Individual
Prefix:MR
First Name:MARK
Middle Name:FREDERICK
Last Name:CARLSON
Suffix:
Gender:M
Credentials:MS, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1603 NE 52ND AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97213-2725
Mailing Address - Country:US
Mailing Address - Phone:503-922-0768
Mailing Address - Fax:503-914-5545
Practice Address - Street 1:1603 NE 52ND AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97213-2725
Practice Address - Country:US
Practice Address - Phone:503-922-0768
Practice Address - Fax:503-914-5545
Is Sole Proprietor?:Yes
Enumeration Date:2009-07-10
Last Update Date:2009-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR12024235Z00000X
WALL00004701235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist