Provider Demographics
NPI:1568521235
Name:CARLSON, CAROLYN (MED, LADC)
Entity Type:Individual
Prefix:
First Name:CAROLYN
Middle Name:
Last Name:CARLSON
Suffix:
Gender:F
Credentials:MED, LADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:38 OLD RIDGEBURY RD
Mailing Address - Street 2:
Mailing Address - City:DANBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06810-5128
Mailing Address - Country:US
Mailing Address - Phone:203-792-4515
Mailing Address - Fax:203-748-2604
Practice Address - Street 1:149 W CORNWALL RD
Practice Address - Street 2:
Practice Address - City:SHARON
Practice Address - State:CT
Practice Address - Zip Code:06069-2105
Practice Address - Country:US
Practice Address - Phone:860-672-6689
Practice Address - Fax:860-672-3021
Is Sole Proprietor?:No
Enumeration Date:2006-12-08
Last Update Date:2012-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT000052101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004257516Medicaid