Basic Information
| Provider Information | |||||||||
| NPI: | 1891875050 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CARLSON | ||||||||
| FirstName: | MARK | ||||||||
| MiddleName: | RICHARD | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PSYD LP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7200 FRANCE AVE | ||||||||
| Address2: | STE 327 | ||||||||
| City: | EDINA | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554354310 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9528352002 | ||||||||
| FaxNumber: | 9528359889 | ||||||||
| Practice Location | |||||||||
| Address1: | 7200 FRANCE AVE | ||||||||
| Address2: | STE 327 | ||||||||
| City: | EDINA | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554354310 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9528352002 | ||||||||
| FaxNumber: | 9528359889 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/16/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103T00000X | LP4345 | MN | Y | Behavioral Health & Social Service Providers | Psychologist |
ID Information
| ID | Type | State | Issuer | Description | 125ROCA | 01 | MN | BCBS | OTHER | 6192920 | 01 | MN | MEDICA | OTHER |