Provider Demographics
NPI:1558482273
Name:CARLSON, MARY PAT (MED)
Entity Type:Individual
Prefix:MS
First Name:MARY
Middle Name:PAT
Last Name:CARLSON
Suffix:
Gender:F
Credentials:MED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 120
Mailing Address - Street 2:
Mailing Address - City:TEXARKANA
Mailing Address - State:TX
Mailing Address - Zip Code:75504-0120
Mailing Address - Country:US
Mailing Address - Phone:903-334-7261
Mailing Address - Fax:903-334-7263
Practice Address - Street 1:3446 SUMMERHILL RD
Practice Address - Street 2:SUITE B
Practice Address - City:TEXARKANA
Practice Address - State:TX
Practice Address - Zip Code:75503-3560
Practice Address - Country:US
Practice Address - Phone:903-334-7261
Practice Address - Fax:903-334-7263
Is Sole Proprietor?:No
Enumeration Date:2007-04-02
Last Update Date:2008-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR18727101YA0400X
101YA0400X
TX8054101YP2500X
TX2644106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist