Provider Demographics
NPI:1609043223
Name:CARLSON, LARRY JAMES (PHD)
Entity Type:Individual
Prefix:DR
First Name:LARRY
Middle Name:JAMES
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 1:2632 FOOTHILL BLVD
Mailing Address - Street 2:SUITE 106
Mailing Address - City:ROCK SPRINGS
Mailing Address - State:WY
Mailing Address - Zip Code:82901-4756
Mailing Address - Country:US
Mailing Address - Phone:307-362-8840
Mailing Address - Fax:307-362-8840
Practice Address - Street 1:2632 FOOTHILL BLVD
Practice Address - Street 2:SUITE 106
Practice Address - City:ROCK SPRINGS
Practice Address - State:WY
Practice Address - Zip Code:82901-4756
Practice Address - Country:US
Practice Address - Phone:307-362-8840
Practice Address - Fax:307-362-8840
Is Sole Proprietor?:No
Enumeration Date:2008-05-13
Last Update Date:2008-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY152103TB0200X, 103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & Behavioral