Provider Demographics
NPI:1467428037
Name:CARLSEN, JOHN THEODORE (PSCYHOLOGIST)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:THEODORE
Last Name:CARLSEN
Suffix:
Gender:M
Credentials:PSCYHOLOGIST
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Mailing Address - Street 1:333 S STATE STREET REVENUE
Mailing Address - Street 2:#200 CHICAGO DEPARTMENT OF PUBLIC HEALTH
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60604
Mailing Address - Country:US
Mailing Address - Phone:312-747-9443
Mailing Address - Fax:312-747-9447
Practice Address - Street 1:333 S STATE STREET REVENUE
Practice Address - Street 2:#200 CHICAGO DEPARTMENT OF PUBLIC HEALTH
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60604
Practice Address - Country:US
Practice Address - Phone:312-747-9442
Practice Address - Fax:312-747-9447
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-02-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IL103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
303330Medicare ID - Type Unspecified