Provider Demographics
NPI:1790262871
Name:CARLSON, CODY LEE (LPC)
Entity Type:Individual
Prefix:MR
First Name:CODY
Middle Name:LEE
Last Name:CARLSON
Suffix:
Gender:M
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4730 DAVIS CIR
Mailing Address - Street 2:
Mailing Address - City:IONA
Mailing Address - State:ID
Mailing Address - Zip Code:83427-5501
Mailing Address - Country:US
Mailing Address - Phone:208-709-6360
Mailing Address - Fax:
Practice Address - Street 1:2275 W BROADWAY ST STE G
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83402-2902
Practice Address - Country:US
Practice Address - Phone:208-524-7400
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-07-23
Last Update Date:2018-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional