Provider Demographics
NPI:1407415433
Name:BRIAN CARLSON MFT
Entity Type:Organization
Organization Name:BRIAN CARLSON MFT
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING
Authorized Official - Prefix:MS
Authorized Official - First Name:CHELI
Authorized Official - Middle Name:
Authorized Official - Last Name:LOPEZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:760-946-9300
Mailing Address - Street 1:18888 US HIGHWAY 18 STE 201
Mailing Address - Street 2:
Mailing Address - City:APPLE VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92307-2315
Mailing Address - Country:US
Mailing Address - Phone:760-946-9300
Mailing Address - Fax:760-946-9300
Practice Address - Street 1:18888 US HIGHWAY 18 STE 201
Practice Address - Street 2:
Practice Address - City:APPLE VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92307-2315
Practice Address - Country:US
Practice Address - Phone:760-946-9300
Practice Address - Fax:760-946-9300
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-06-12
Last Update Date:2019-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty