Provider Demographics
NPI:1700365517
Name:CARLSON, JOHN E
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:E
Last Name:CARLSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 307
Mailing Address - Street 2:
Mailing Address - City:MARLETTE
Mailing Address - State:MI
Mailing Address - Zip Code:48453-0307
Mailing Address - Country:US
Mailing Address - Phone:800-635-7490
Mailing Address - Fax:989-635-4145
Practice Address - Street 1:2770 MAIN ST
Practice Address - Street 2:
Practice Address - City:MARLETTE
Practice Address - State:MI
Practice Address - Zip Code:48453-1141
Practice Address - Country:US
Practice Address - Phone:800-635-7490
Practice Address - Fax:989-635-4145
Is Sole Proprietor?:No
Enumeration Date:2018-08-13
Last Update Date:2018-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010893581041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical