Provider Demographics
NPI:1396035994
Name:CARLSON, RICHARD HARLAN JR
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:HARLAN
Last Name:CARLSON
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 421
Mailing Address - Street 2:
Mailing Address - City:LIBERTY LAKE
Mailing Address - State:WA
Mailing Address - Zip Code:99019-0421
Mailing Address - Country:US
Mailing Address - Phone:509-624-2313
Mailing Address - Fax:
Practice Address - Street 1:104 W 5TH AVE
Practice Address - Street 2:STE. 330W
Practice Address - City:SPOKANE
Practice Address - State:WA
Practice Address - Zip Code:99204-4880
Practice Address - Country:US
Practice Address - Phone:509-624-2313
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-04-15
Last Update Date:2016-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
WAMD606413252084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program