Provider Demographics
NPI:1790839595
Name:CARSON, LEE FULTON (MSW, LSW)
Entity Type:Individual
Prefix:MR
First Name:LEE
Middle Name:FULTON
Last Name:CARSON
Suffix:
Gender:M
Credentials:MSW, LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1428 WOLF ST
Mailing Address - Street 2:APARTMENT #3
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19145-4448
Mailing Address - Country:US
Mailing Address - Phone:267-765-2352
Mailing Address - Fax:
Practice Address - Street 1:1201 CHESTNUT ST
Practice Address - Street 2:2ND FLOOR
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19107-4123
Practice Address - Country:US
Practice Address - Phone:215-563-0652
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASW125607101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health