Provider Demographics
NPI:1457619546
Name:CARLSON, STEPHANIE (MS ED)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:
Last Name:CARLSON
Suffix:
Gender:F
Credentials:MS ED
Other - Prefix:MRS
Other - First Name:STEPHANIE
Other - Middle Name:
Other - Last Name:SMITH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MS ED
Mailing Address - Street 1:75 GALLIS HILL RD
Mailing Address - Street 2:
Mailing Address - City:KINGSTON
Mailing Address - State:NY
Mailing Address - Zip Code:12401-7505
Mailing Address - Country:US
Mailing Address - Phone:845-336-8603
Mailing Address - Fax:
Practice Address - Street 1:75 GALLIS HILL RD
Practice Address - Street 2:
Practice Address - City:KINGSTON
Practice Address - State:NY
Practice Address - Zip Code:12401-7505
Practice Address - Country:US
Practice Address - Phone:845-336-8603
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-04-26
Last Update Date:2012-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY84149981174H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174H00000XOther Service ProvidersHealth Educator
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY84149981OtherSPECIAL EDUCATION TEACHER LICENCE #