Provider Demographics
NPI:1689725368
Name:CARLSON, VIRGINIA H (MS)
Entity Type:Individual
Prefix:MRS
First Name:VIRGINIA
Middle Name:H
Last Name:CARLSON
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8729 N 95TH AVE
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:AZ
Mailing Address - Zip Code:85345-7723
Mailing Address - Country:US
Mailing Address - Phone:623-825-3536
Mailing Address - Fax:
Practice Address - Street 1:21419 W. DOVE VALLEY ROAD
Practice Address - Street 2:
Practice Address - City:WITTMANN
Practice Address - State:AZ
Practice Address - Zip Code:85361
Practice Address - Country:US
Practice Address - Phone:623-388-2321
Practice Address - Fax:623-388-2915
Is Sole Proprietor?:No
Enumeration Date:2007-01-16
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZSLP0172235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ856651Medicaid