Basic Information
| Provider Information | |||||||||
| NPI: | 1356657340 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CARLSON | ||||||||
| FirstName: | TRACY | ||||||||
| MiddleName: | NICOLE | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PH.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | CARLSON | ||||||||
| OtherFirstName: | TRACY | ||||||||
| OtherMiddleName: | N | ||||||||
| OtherNamePrefix: | DR. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | PHD | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1300 SOUTH 2ND STREET, SUITE 180 | ||||||||
| Address2: | CENTER FOR SEXUAL HEALTH | ||||||||
| City: | MINNEAPOLIS | ||||||||
| State: | MN | ||||||||
| PostalCode: | 55454 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6126251500 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 200 W ESPLANADE AVE STE 412 | ||||||||
| Address2: | |||||||||
| City: | KENNER | ||||||||
| State: | LA | ||||||||
| PostalCode: | 700652475 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5044642940 | ||||||||
| FaxNumber: | 5044642941 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/27/2010 | ||||||||
| LastUpdateDate: | 09/17/2018 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TC1900X | 1405 | LA | N | Behavioral Health & Social Service Providers | Psychologist | Counseling | 103TC1900X | Y | Behavioral Health & Social Service Providers | Psychologist | Counseling |
No ID Information.