Basic Information
| Provider Information | |||||||||
| NPI: | 1679021166 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CARLSON | ||||||||
| FirstName: | MARY | ||||||||
| MiddleName: | L | ||||||||
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| Credential: | MS, LPC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 13502 E 53RD TER | ||||||||
| Address2: | |||||||||
| City: | KANSAS CITY | ||||||||
| State: | MO | ||||||||
| PostalCode: | 641337733 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8163925734 | ||||||||
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| Practice Location | |||||||||
| Address1: | 6100 WESTERN PL STE 908 | ||||||||
| Address2: | |||||||||
| City: | FORT WORTH | ||||||||
| State: | TX | ||||||||
| PostalCode: | 761074600 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8448248775 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/14/2016 | ||||||||
| LastUpdateDate: | 10/07/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 10/07/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YP2500X | 2014030086 | MO | N | Behavioral Health & Social Service Providers | Counselor | Professional | 101YP2500X | 79257 | TX | Y | Behavioral Health & Social Service Providers | Counselor | Professional |
No ID Information.