Provider Demographics
NPI:1972197135
Name:CARLSON, KAMRYN JUDITH (LMSW)
Entity Type:Individual
Prefix:
First Name:KAMRYN
Middle Name:JUDITH
Last Name:CARLSON
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:655 RUBY CIR UNIT 301
Mailing Address - Street 2:
Mailing Address - City:SHELLEY
Mailing Address - State:ID
Mailing Address - Zip Code:83274-1023
Mailing Address - Country:US
Mailing Address - Phone:208-481-7606
Mailing Address - Fax:
Practice Address - Street 1:452 D ST
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83402-3531
Practice Address - Country:US
Practice Address - Phone:208-552-0355
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-02-26
Last Update Date:2021-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLMSW-40263104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker