Provider Demographics
NPI:1497854418
Name:CARLSON, CHRISTOPHER R (PHD)
Entity Type:Individual
Prefix:
First Name:CHRISTOPHER
Middle Name:R
Last Name:CARLSON
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:567 VAUXHALL STREET EXT
Mailing Address - Street 2:STE 315
Mailing Address - City:WATERFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06385-4330
Mailing Address - Country:US
Mailing Address - Phone:860-447-2442
Mailing Address - Fax:
Practice Address - Street 1:567 VAUXHALL STREET EXT
Practice Address - Street 2:STE 315
Practice Address - City:WATERFORD
Practice Address - State:CT
Practice Address - Zip Code:06385-4330
Practice Address - Country:US
Practice Address - Phone:860-447-2442
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-22
Last Update Date:2009-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT001655103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT680000381Medicare PIN