Provider Demographics
NPI:1679218754
Name:CARLSON, ANTOINETTE PEARL (LSW)
Entity Type:Individual
Prefix:
First Name:ANTOINETTE
Middle Name:PEARL
Last Name:CARLSON
Suffix:
Gender:F
Credentials:LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:113 COMANCHE RD
Mailing Address - Street 2:
Mailing Address - City:FORT MEADE
Mailing Address - State:SD
Mailing Address - Zip Code:57741-1002
Mailing Address - Country:US
Mailing Address - Phone:056-347-2144
Mailing Address - Fax:
Practice Address - Street 1:500 N 5TH ST
Practice Address - Street 2:
Practice Address - City:HOT SPRINGS
Practice Address - State:SD
Practice Address - Zip Code:57747-1480
Practice Address - Country:US
Practice Address - Phone:605-745-2000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-05-03
Last Update Date:2024-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASW138966104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker