Provider Demographics
NPI:1841596434
Name:CARLSON, WALTER (MED, CADC, LCPC)
Entity Type:Individual
Prefix:MR
First Name:WALTER
Middle Name:
Last Name:CARLSON
Suffix:
Gender:M
Credentials:MED, CADC, LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1731 N MARCEY ST STE 535
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60614-7965
Mailing Address - Country:US
Mailing Address - Phone:312-280-1166
Mailing Address - Fax:312-280-1199
Practice Address - Street 1:1731 N MARCEY ST STE 535
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60614-7965
Practice Address - Country:US
Practice Address - Phone:312-280-1166
Practice Address - Fax:312-280-1199
Is Sole Proprietor?:Yes
Enumeration Date:2011-01-31
Last Update Date:2011-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL6409101YA0400X
IL180003891101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)