Provider Demographics
NPI:1760693956
Name:CARLSON, JOHN STEVEN (PHD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:STEVEN
Last Name:CARLSON
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:964 LANTERN HILL DR
Mailing Address - Street 2:
Mailing Address - City:EAST LANSING
Mailing Address - State:MI
Mailing Address - Zip Code:48823-2832
Mailing Address - Country:US
Mailing Address - Phone:517-282-7717
Mailing Address - Fax:
Practice Address - Street 1:601 ABBOTT RD
Practice Address - Street 2:SUITE 101
Practice Address - City:EAST LANSING
Practice Address - State:MI
Practice Address - Zip Code:48823-3366
Practice Address - Country:US
Practice Address - Phone:517-282-7717
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-27
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301011692103TC2200X, 103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent
Not Answered103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI11273210OtherCAQH PROVIDER ID NUMBER
MIOC34726Medicare UPIN