Provider Demographics
NPI:1659381507
Name:CARLSON, STANLEY E (MDIV,LMHP,CPC,LADC,)
Entity Type:Individual
Prefix:MR
First Name:STANLEY
Middle Name:E
Last Name:CARLSON
Suffix:
Gender:M
Credentials:MDIV,LMHP,CPC,LADC,
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:230 E 22ND ST
Mailing Address - Street 2:SUITE #3
Mailing Address - City:FREMONT
Mailing Address - State:NE
Mailing Address - Zip Code:68025-2661
Mailing Address - Country:US
Mailing Address - Phone:402-721-8805
Mailing Address - Fax:412-727-4839
Practice Address - Street 1:230 E 22ND ST
Practice Address - Street 2:SUITE #3
Practice Address - City:FREMONT
Practice Address - State:NE
Practice Address - Zip Code:68025-2661
Practice Address - Country:US
Practice Address - Phone:402-721-8805
Practice Address - Fax:412-727-4839
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-09
Last Update Date:2021-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE683101YA0400X
NE2105101YM0800X
NE1200101YP2500X
NE18101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE10025637500Medicaid
NE10025820000Medicaid