Provider Demographics
NPI:1679777692
Name:CARLSON, MARY LAVIS
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:LAVIS
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 1:144 E 84TH ST
Mailing Address - Street 2:12H
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10028-2004
Mailing Address - Country:US
Mailing Address - Phone:212-879-0788
Mailing Address - Fax:
Practice Address - Street 1:460 W 34TH ST
Practice Address - Street 2:11TH FLOOR
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10001-2320
Practice Address - Country:US
Practice Address - Phone:212-273-6100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY464908OtherLICENSE NUMBER