Provider Demographics
NPI:1750523189
Name:CARLSON, JOHN D (MSW)
Entity type:Individual
Prefix:MR
First Name:JOHN
Middle Name:D
Last Name:CARLSON
Suffix:
Gender:M
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:221 3RD ST W
Mailing Address - Street 2:
Mailing Address - City:JBSA RANDOLPH
Mailing Address - State:TX
Mailing Address - Zip Code:78150-4800
Mailing Address - Country:US
Mailing Address - Phone:402-779-1008
Mailing Address - Fax:
Practice Address - Street 1:221 3RD ST W
Practice Address - Street 2:
Practice Address - City:JBSA RANDOLPH
Practice Address - State:TX
Practice Address - Zip Code:78150-4800
Practice Address - Country:US
Practice Address - Phone:210-652-6403
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-03-31
Last Update Date:2023-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE757101YM0800X
NE13731041C0700X
IA067981041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA600661039Medicaid
IA600661039Medicaid