Provider Demographics
NPI:1891303079
Name:CARLSON, WILLIAM CLEMENTS (LICSW)
Entity Type:Individual
Prefix:
First Name:WILLIAM
Middle Name:CLEMENTS
Last Name:CARLSON
Suffix:
Gender:M
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:621 W LAKE ST
Mailing Address - Street 2:STE 350
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55408-2952
Mailing Address - Country:US
Mailing Address - Phone:612-979-2276
Mailing Address - Fax:651-925-0427
Practice Address - Street 1:621 W LAKE ST STE 350
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55408-2952
Practice Address - Country:US
Practice Address - Phone:612-979-2276
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-07-14
Last Update Date:2020-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN264281041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical