Provider Demographics
NPI:1508318403
Name:CARLSON, GARY (REGISTERED INTERN)
Entity Type:Individual
Prefix:MR
First Name:GARY
Middle Name:
Last Name:CARLSON
Suffix:
Gender:M
Credentials:REGISTERED INTERN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10770 N 46TH ST
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33617-3442
Mailing Address - Country:US
Mailing Address - Phone:813-631-2588
Mailing Address - Fax:
Practice Address - Street 1:10770 N 46TH ST
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33617-3442
Practice Address - Country:US
Practice Address - Phone:813-631-2588
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-10-27
Last Update Date:2016-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLIMH 14421101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLIMH 14421OtherSTATE OF FLORIDA