Provider Demographics
NPI:1619020823
Name:CARLSEN, SUSAN GAYLE (MACCCSIP A)
Entity Type:Individual
Prefix:MRS
First Name:SUSAN
Middle Name:GAYLE
Last Name:CARLSEN
Suffix:
Gender:F
Credentials:MACCCSIP A
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1605 CAMINO RIO
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON
Mailing Address - State:NM
Mailing Address - Zip Code:87401-8043
Mailing Address - Country:US
Mailing Address - Phone:505-320-6325
Mailing Address - Fax:505-325-4658
Practice Address - Street 1:1605 CAMINO RIO
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:NM
Practice Address - Zip Code:87401-8043
Practice Address - Country:US
Practice Address - Phone:505-320-6325
Practice Address - Fax:505-325-4658
Is Sole Proprietor?:No
Enumeration Date:2007-01-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM052A235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist