Provider Demographics
NPI:1861818569
Name:CARLSON, DANIEL (PSYD)
Entity Type:Individual
Prefix:
First Name:DANIEL
Middle Name:
Last Name:CARLSON
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3101 SUPERIOR DR NW
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:MN
Mailing Address - Zip Code:55901-1993
Mailing Address - Country:US
Mailing Address - Phone:507-288-8544
Mailing Address - Fax:507-288-8545
Practice Address - Street 1:1500 1ST AVE NE
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:MN
Practice Address - Zip Code:55906-4170
Practice Address - Country:US
Practice Address - Phone:507-536-0584
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-03-05
Last Update Date:2020-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP4131103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical