Provider Demographics
NPI:1881767473
Name:CARLSON, KELLY BLANCHE (MC)
Entity type:Individual
Prefix:MS
First Name:KELLY
Middle Name:BLANCHE
Last Name:CARLSON
Suffix:
Gender:F
Credentials:MC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15821 E KIM DR
Mailing Address - Street 2:
Mailing Address - City:FOUNTAIN HILLS
Mailing Address - State:AZ
Mailing Address - Zip Code:85268-1827
Mailing Address - Country:US
Mailing Address - Phone:480-734-7870
Mailing Address - Fax:480-837-4957
Practice Address - Street 1:3603 N 7TH AVE
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85013-3638
Practice Address - Country:US
Practice Address - Phone:602-234-1935
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLPC 10451101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health