Provider Demographics
NPI:1841206075
Name:CARLSON, RONALD GAYLORD (PSY D)
Entity Type:Individual
Prefix:
First Name:RONALD
Middle Name:GAYLORD
Last Name:CARLSON
Suffix:
Gender:M
Credentials:PSY D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:680 LANGSDORF DR
Mailing Address - Street 2:SUITE #219
Mailing Address - City:FULLERTON
Mailing Address - State:CA
Mailing Address - Zip Code:92831
Mailing Address - Country:US
Mailing Address - Phone:714-578-0990
Mailing Address - Fax:714-449-9252
Practice Address - Street 1:680 LANGSDORF DR
Practice Address - Street 2:SUITE #219
Practice Address - City:FULLERTON
Practice Address - State:CA
Practice Address - Zip Code:92831
Practice Address - Country:US
Practice Address - Phone:714-578-0990
Practice Address - Fax:714-449-9252
Is Sole Proprietor?:No
Enumeration Date:2006-07-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY9984103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CP9984Medicare ID - Type Unspecified