Provider Demographics
NPI:1295461622
Name:CARSON, JOHN DAVID (T-LMAC)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:DAVID
Last Name:CARSON
Suffix:
Gender:M
Credentials:T-LMAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3000 GRAND MERE PKWY APT 16
Mailing Address - Street 2:
Mailing Address - City:MANHATTAN
Mailing Address - State:KS
Mailing Address - Zip Code:66503-8650
Mailing Address - Country:US
Mailing Address - Phone:785-564-3854
Mailing Address - Fax:
Practice Address - Street 1:2304 SKYVUE LN
Practice Address - Street 2:
Practice Address - City:MANHATTAN
Practice Address - State:KS
Practice Address - Zip Code:66502-3178
Practice Address - Country:US
Practice Address - Phone:785-320-5505
Practice Address - Fax:785-320-5517
Is Sole Proprietor?:Yes
Enumeration Date:2022-07-27
Last Update Date:2022-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
01074101YA0400X
KS01074101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)