Provider Demographics
NPI:1659943298
Name:CARLSON, ABIGAIL
Entity type:Individual
Prefix:
First Name:ABIGAIL
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 1:120 STEVENS ST SW
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49507-1526
Mailing Address - Country:US
Mailing Address - Phone:855-832-6727
Mailing Address - Fax:
Practice Address - Street 1:1260 BUTH DR NE
Practice Address - Street 2:
Practice Address - City:COMSTOCK PARK
Practice Address - State:MI
Practice Address - Zip Code:49321-9501
Practice Address - Country:US
Practice Address - Phone:616-279-6414
Practice Address - Fax:616-323-3966
Is Sole Proprietor?:No
Enumeration Date:2021-07-13
Last Update Date:2024-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68511108561041C0700X
106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician