Provider Demographics
NPI:1730300047
Name:CARLSON, JOHN G (PHD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:G
Last Name:CARLSON
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:DR
Other - First Name:JOHN
Other - Middle Name:G
Other - Last Name:CARLSON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PHD
Mailing Address - Street 1:5930 E PIMA ST
Mailing Address - Street 2:STE 120
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85712-4300
Mailing Address - Country:US
Mailing Address - Phone:520-981-5930
Mailing Address - Fax:520-885-6500
Practice Address - Street 1:6612 E CARONDELET DR
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85710-2119
Practice Address - Country:US
Practice Address - Phone:520-981-5930
Practice Address - Fax:520-885-6500
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-02
Last Update Date:2020-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ3324103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical