Provider Demographics
NPI:1508445040
Name:CARLSON, MALLORY (LMHC)
Entity Type:Individual
Prefix:
First Name:MALLORY
Middle Name:
Last Name:CARLSON
Suffix:
Gender:F
Credentials:LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3932 CONSTANTINE LOOP
Mailing Address - Street 2:
Mailing Address - City:WESLEY CHAPEL
Mailing Address - State:FL
Mailing Address - Zip Code:33543-4913
Mailing Address - Country:US
Mailing Address - Phone:954-612-6622
Mailing Address - Fax:
Practice Address - Street 1:3932 CONSTANTINE LOOP
Practice Address - Street 2:
Practice Address - City:WESLEY CHAPEL
Practice Address - State:FL
Practice Address - Zip Code:33543-4913
Practice Address - Country:US
Practice Address - Phone:954-612-6622
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-02
Last Update Date:2021-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH18421101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health