Provider Demographics
NPI:1205471968
Name:CARLSON, STEPHANY
Entity type:Individual
Prefix:
First Name:STEPHANY
Middle Name:
Last Name:CARLSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:836 MESILLA DR
Mailing Address - Street 2:
Mailing Address - City:CHAPARRAL
Mailing Address - State:NM
Mailing Address - Zip Code:88081-7619
Mailing Address - Country:US
Mailing Address - Phone:575-618-0375
Mailing Address - Fax:
Practice Address - Street 1:836 MESILLA DR
Practice Address - Street 2:
Practice Address - City:CHAPARRAL
Practice Address - State:NM
Practice Address - Zip Code:88081-7619
Practice Address - Country:US
Practice Address - Phone:575-618-0375
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-11-16
Last Update Date:2019-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician