Provider Demographics
NPI:1710102595
Name:CARLSON, CAROL ANN (DOCTORATE - PHD)
Entity Type:Individual
Prefix:DR
First Name:CAROL
Middle Name:ANN
Last Name:CARLSON
Suffix:
Gender:F
Credentials:DOCTORATE - PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1200 LAKESHORE AVE
Mailing Address - Street 2:SUITE 18C
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94606-1679
Mailing Address - Country:US
Mailing Address - Phone:510-494-9229
Mailing Address - Fax:510-625-8665
Practice Address - Street 1:1700 S EL CAMINO REAL
Practice Address - Street 2:SUITE 505
Practice Address - City:SAN MATEO
Practice Address - State:CA
Practice Address - Zip Code:94402-3047
Practice Address - Country:US
Practice Address - Phone:650-525-9555
Practice Address - Fax:650-345-6748
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-16
Last Update Date:2007-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY14518103T00000X, 103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA0PL145180OtherBLUE SHIELD PROVIDER #