Provider Demographics
NPI:1336364199
Name:CARSON, GREGORY D (LCSW)
Entity Type:Individual
Prefix:MR
First Name:GREGORY
Middle Name:D
Last Name:CARSON
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16 CAROLIN RD
Mailing Address - Street 2:
Mailing Address - City:UPPER MONTCLAIR
Mailing Address - State:NJ
Mailing Address - Zip Code:07043-2224
Mailing Address - Country:US
Mailing Address - Phone:917-796-2760
Mailing Address - Fax:
Practice Address - Street 1:156 5TH AVE STE 725
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10010-7772
Practice Address - Country:US
Practice Address - Phone:917-796-2760
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0706451041C0700X
NJ44SC052573001041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYNX7461Medicare ID - Type Unspecified
NJ092327Medicare ID - Type Unspecified