Provider Demographics
NPI:1710014683
Name:CARLSON, PETER GUSTAV (MA, MFT)
Entity Type:Individual
Prefix:MR
First Name:PETER
Middle Name:GUSTAV
Last Name:CARLSON
Suffix:
Gender:M
Credentials:MA, MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:23210 CRENSHAW BLVD STE 250
Mailing Address - Street 2:
Mailing Address - City:TORRANCE
Mailing Address - State:CA
Mailing Address - Zip Code:90505-3180
Mailing Address - Country:US
Mailing Address - Phone:310-325-8787
Mailing Address - Fax:310-547-1543
Practice Address - Street 1:23210 CRENSHAW BLVD STE 250
Practice Address - Street 2:
Practice Address - City:TORRANCE
Practice Address - State:CA
Practice Address - Zip Code:90505-3180
Practice Address - Country:US
Practice Address - Phone:310-325-8787
Practice Address - Fax:310-547-1543
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-27
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC19950106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAMF1995000Medicaid
CAMF1995000Medicaid