Provider Demographics
NPI:1659705739
Name:CARLSON, SUSAN ELIZABETH
Entity Type:Individual
Prefix:MRS
First Name:SUSAN
Middle Name:ELIZABETH
Last Name:CARLSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:455 RIVER BLUFF DR
Mailing Address - Street 2:
Mailing Address - City:DIXON
Mailing Address - State:IL
Mailing Address - Zip Code:61021-8767
Mailing Address - Country:US
Mailing Address - Phone:815-973-3311
Mailing Address - Fax:
Practice Address - Street 1:325 IL ROUTE 2
Practice Address - Street 2:
Practice Address - City:DIXON
Practice Address - State:IL
Practice Address - Zip Code:61021-9118
Practice Address - Country:US
Practice Address - Phone:815-284-6611
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-08-26
Last Update Date:2013-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health