Provider Demographics
NPI:1619497443
Name:CARLSON, BREA (CCC-SLP, IBCLC)
Entity Type:Individual
Prefix:
First Name:BREA
Middle Name:
Last Name:CARLSON
Suffix:
Gender:F
Credentials:CCC-SLP, IBCLC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2837 HENDERSON ST
Mailing Address - Street 2:
Mailing Address - City:WEST LAFAYETTE
Mailing Address - State:IN
Mailing Address - Zip Code:47906-1540
Mailing Address - Country:US
Mailing Address - Phone:765-267-1977
Mailing Address - Fax:
Practice Address - Street 1:2837 HENDERSON ST
Practice Address - Street 2:
Practice Address - City:WEST LAFAYETTE
Practice Address - State:IN
Practice Address - Zip Code:47906-1540
Practice Address - Country:US
Practice Address - Phone:765-267-1977
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-06-22
Last Update Date:2023-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
L-127002174N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174N00000XOther Service ProvidersLactation Consultant, Non-RN