Provider Demographics
NPI:1639223720
Name:CARLSON, VICTOR BRYAN (PSYD LCADC)
Entity Type:Individual
Prefix:DR
First Name:VICTOR
Middle Name:BRYAN
Last Name:CARLSON
Suffix:
Gender:M
Credentials:PSYD LCADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:64 SMITH RD
Mailing Address - Street 2:
Mailing Address - City:DENVILLE
Mailing Address - State:NJ
Mailing Address - Zip Code:07834
Mailing Address - Country:US
Mailing Address - Phone:973-328-4506
Mailing Address - Fax:
Practice Address - Street 1:288 NEWTON SPARTA RD
Practice Address - Street 2:
Practice Address - City:NEWTON
Practice Address - State:NJ
Practice Address - Zip Code:07860
Practice Address - Country:US
Practice Address - Phone:973-229-4209
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ35SI00304300103T00000X
NJ37LC00080400103TA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered103T00000XBehavioral Health & Social Service ProvidersPsychologist
Not Answered103TA0400XBehavioral Health & Social Service ProvidersPsychologistAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ087230Medicare ID - Type Unspecified