Provider Demographics
NPI:1538104575
Name:CARLSON, DIANE L (LICSW)
Entity Type:Individual
Prefix:
First Name:DIANE
Middle Name:L
Last Name:CARLSON
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:115 MAIN ST STE 2D
Mailing Address - Street 2:
Mailing Address - City:NORTH EASTON
Mailing Address - State:MA
Mailing Address - Zip Code:02356-1469
Mailing Address - Country:US
Mailing Address - Phone:508-238-7766
Mailing Address - Fax:508-230-5089
Practice Address - Street 1:115 MAIN ST STE 2D
Practice Address - Street 2:
Practice Address - City:NORTH EASTON
Practice Address - State:MA
Practice Address - Zip Code:02356-1469
Practice Address - Country:US
Practice Address - Phone:508-238-7766
Practice Address - Fax:508-230-5089
Is Sole Proprietor?:No
Enumeration Date:2006-06-16
Last Update Date:2010-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1004781041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA761754OtherTUFTS HEALTH PLAN
MAPO1190OtherMASS BC BS ID
MAPO1190OtherMASS BC BS ID