Provider Demographics
NPI:1437431319
Name:CARLSON, VIVIAN DALE
Entity Type:Individual
Prefix:MS
First Name:VIVIAN
Middle Name:DALE
Last Name:CARLSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:VINNIE
Other - Middle Name:DALE
Other - Last Name:CARLSON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:1213 FIELDSTONE WAY
Mailing Address - Street 2:
Mailing Address - City:MUSTANG
Mailing Address - State:OK
Mailing Address - Zip Code:73064-7010
Mailing Address - Country:US
Mailing Address - Phone:320-310-6888
Mailing Address - Fax:
Practice Address - Street 1:4545 N LINCOLN BLVD
Practice Address - Street 2:105
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73105-3418
Practice Address - Country:US
Practice Address - Phone:405-501-8405
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-15
Last Update Date:2014-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor