Provider Demographics
NPI:1891875050
Name:CARLSON, MARK RICHARD (PSYD LP)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:RICHARD
Last Name:CARLSON
Suffix:
Gender:M
Credentials:PSYD LP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7200 FRANCE AVE
Mailing Address - Street 2:STE 327
Mailing Address - City:EDINA
Mailing Address - State:MN
Mailing Address - Zip Code:55435-4310
Mailing Address - Country:US
Mailing Address - Phone:952-835-2002
Mailing Address - Fax:952-835-9889
Practice Address - Street 1:7200 FRANCE AVE
Practice Address - Street 2:STE 327
Practice Address - City:EDINA
Practice Address - State:MN
Practice Address - Zip Code:55435-4310
Practice Address - Country:US
Practice Address - Phone:952-835-2002
Practice Address - Fax:952-835-9889
Is Sole Proprietor?:No
Enumeration Date:2006-10-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP4345103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN125ROCAOtherBCBS
MN6192920OtherMEDICA