Provider Demographics
NPI:1427359561
Name:CARLSON, MARY ELLEN
Entity Type:Individual
Prefix:
First Name:MARY ELLEN
Middle Name:
Last Name:CARLSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MARY ELLEN
Other - Middle Name:
Other - Last Name:RUETTING
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2205 ROCKY MOUNTAIN AVE
Mailing Address - Street 2:UNIT 302
Mailing Address - City:LOVELAND
Mailing Address - State:CO
Mailing Address - Zip Code:80538-8843
Mailing Address - Country:US
Mailing Address - Phone:253-394-1054
Mailing Address - Fax:
Practice Address - Street 1:2205 ROCKY MOUNTAIN AVE
Practice Address - Street 2:UNIT 302
Practice Address - City:LOVELAND
Practice Address - State:CO
Practice Address - Zip Code:80538-8843
Practice Address - Country:US
Practice Address - Phone:253-394-1054
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-11-05
Last Update Date:2017-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACG60132886101Y00000X
CO0014899101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor