Provider Demographics
NPI:1679021166
Name:CARLSON, MARY L (MS, LPC)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:L
Last Name:CARLSON
Suffix:
Gender:F
Credentials:MS, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13502 E 53RD TER
Mailing Address - Street 2:
Mailing Address - City:KANSAS CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64133-7733
Mailing Address - Country:US
Mailing Address - Phone:816-392-5734
Mailing Address - Fax:
Practice Address - Street 1:6100 WESTERN PL STE 908
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76107-4600
Practice Address - Country:US
Practice Address - Phone:844-824-8775
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-14
Last Update Date:2022-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2014030086101YP2500X
TX79257101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional