Provider Demographics
NPI:1396005989
Name:CARLSON, JOHN V (PHD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:V
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 1:10 AVONDALE RD
Mailing Address - Street 2:
Mailing Address - City:MANCHESTER
Mailing Address - State:CT
Mailing Address - Zip Code:06042-3258
Mailing Address - Country:US
Mailing Address - Phone:860-305-3024
Mailing Address - Fax:
Practice Address - Street 1:300 SUMMIT ST
Practice Address - Street 2:
Practice Address - City:HARTFORD
Practice Address - State:CT
Practice Address - Zip Code:06106-3100
Practice Address - Country:US
Practice Address - Phone:860-305-3024
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-05-17
Last Update Date:2012-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT003138103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical