Basic Information
| Provider Information | |||||||||
| NPI: | 1255967212 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CARLSON PSYCHOTHERAPY SERVICES INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2810 E DEL MAR BLVD STE 12 | ||||||||
| Address2: | |||||||||
| City: | PASADENA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 911076709 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6265850041 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2810 E DEL MAR BLVD STE 12 | ||||||||
| Address2: | |||||||||
| City: | PASADENA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 911076709 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6265850041 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/20/2020 | ||||||||
| LastUpdateDate: | 03/20/2020 | ||||||||
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| AuthorizedOfficialLastName: | CARLSON | ||||||||
| AuthorizedOfficialFirstName: | WENDY | ||||||||
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| AuthorizedOfficialTitleorPosition: | OWNER/CEO | ||||||||
| AuthorizedOfficialTelephone: | 6264214630 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | LCSW | ||||||||
| NPICertificationDate: | 03/20/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM0855X | N | Ambulatory Health Care Facilities | Clinic/Center | Adolescent and Children Mental Health | 261QM0850X | Y | Ambulatory Health Care Facilities | Clinic/Center | Adult Mental Health |
No ID Information.