Provider Demographics
NPI:1467586461
Name:CARLSON, KIMBERLY S (MA)
Entity Type:Individual
Prefix:MS
First Name:KIMBERLY
Middle Name:S
Last Name:CARLSON
Suffix:
Gender:F
Credentials:MA
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 998
Mailing Address - Street 2:
Mailing Address - City:CHEHALIS
Mailing Address - State:WA
Mailing Address - Zip Code:98532-0169
Mailing Address - Country:US
Mailing Address - Phone:360-740-6264
Mailing Address - Fax:360-740-6265
Practice Address - Street 1:34 NE BOISTFORT ST STE 101
Practice Address - Street 2:
Practice Address - City:CHEHALIS
Practice Address - State:WA
Practice Address - Zip Code:98532-2600
Practice Address - Country:US
Practice Address - Phone:360-740-6264
Practice Address - Fax:360-740-6265
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-14
Last Update Date:2017-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALH00011172101YM0800X
WA404607D101YS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YS0200XBehavioral Health & Social Service ProvidersCounselorSchool