Provider Demographics
NPI:1518185115
Name:CARLSON, ROGER DAVID (PHD)
Entity Type:Individual
Prefix:DR
First Name:ROGER
Middle Name:DAVID
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 1:9450 SW 52ND AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97219-5040
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1838 SW JEFFERSON ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97201-2463
Practice Address - Country:US
Practice Address - Phone:503-245-2929
Practice Address - Fax:503-245-4478
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-22
Last Update Date:2018-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR1511103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist