Provider Demographics
NPI:1609865351
Name:CARLSON, SANDRA R (LCSW, LMFT)
Entity Type:Individual
Prefix:
First Name:SANDRA
Middle Name:R
Last Name:CARLSON
Suffix:
Gender:F
Credentials:LCSW, LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:601 WALL ST
Mailing Address - Street 2:
Mailing Address - City:VALPARAISO
Mailing Address - State:IN
Mailing Address - Zip Code:46383-2512
Mailing Address - Country:US
Mailing Address - Phone:219-531-3500
Mailing Address - Fax:219-462-3975
Practice Address - Street 1:601 WALL ST
Practice Address - Street 2:
Practice Address - City:VALPARAISO
Practice Address - State:IN
Practice Address - Zip Code:46383-2512
Practice Address - Country:US
Practice Address - Phone:219-531-3500
Practice Address - Fax:219-462-3975
Is Sole Proprietor?:No
Enumeration Date:2005-10-16
Last Update Date:2007-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN34001594A1041C0700X
IN35000829A106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
INS10481Medicare UPIN