1033353289 NPI number — ROBERTA J CARLSON MS, LMFT, LSW

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1033353289 NPI number — ROBERTA J CARLSON MS, LMFT, LSW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CARLSON
Provider First Name:
ROBERTA
Provider Middle Name:
J
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MS, LMFT, LSW
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1033353289
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/26/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
25806 W BASS LAKE RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WEBSTER
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
54893-8637
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
715-866-4802
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
100 POLK COUNTY PLZ
Provider Second Line Business Practice Location Address:
SUITE 50
Provider Business Practice Location Address City Name:
BALSAM LAKE
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
54810-9071
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
715-485-8465
Provider Business Practice Location Address Fax Number:
715-485-8490
Provider Enumeration Date:
04/30/2009

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 101YM0800X , with the licence number:  828-124 , registered in the state of WI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 1041C0700X , with the licence number: 9945-120 , registered in the state of WI ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)





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