Provider Demographics
NPI:1255348520
Name:CARLSON, KRISTINE LEIGH (LCSW)
Entity type:Individual
Prefix:MS
First Name:KRISTINE
Middle Name:LEIGH
Last Name:CARLSON
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7601 OLD AZTEC HWY
Mailing Address - Street 2:
Mailing Address - City:FLORA VISTA
Mailing Address - State:NM
Mailing Address - Zip Code:87415-9632
Mailing Address - Country:US
Mailing Address - Phone:505-326-0664
Mailing Address - Fax:
Practice Address - Street 1:1615 OJO COURT
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:NM
Practice Address - Zip Code:87401-5638
Practice Address - Country:US
Practice Address - Phone:505-564-4804
Practice Address - Fax:505-564-4857
Is Sole Proprietor?:No
Enumeration Date:2006-08-01
Last Update Date:2020-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMOOR75EOtherBCBS PROVIDER #