Provider Demographics
NPI:1497126882
Name:CARLSON, SUSAN KATHRYN (MA COUNSELING)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:KATHRYN
Last Name:CARLSON
Suffix:
Gender:F
Credentials:MA COUNSELING
Other - Prefix:
Other - First Name:SUSAN
Other - Middle Name:KATHRYN
Other - Last Name:DAVIS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LPC
Mailing Address - Street 1:272 NW MEDICAL LOOP
Mailing Address - Street 2:SUITE E
Mailing Address - City:ROSEBURG
Mailing Address - State:OR
Mailing Address - Zip Code:97471-5545
Mailing Address - Country:US
Mailing Address - Phone:541-900-4285
Mailing Address - Fax:888-810-2993
Practice Address - Street 1:3400 STATE STREET
Practice Address - Street 2:SUITE G750
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97301-7012
Practice Address - Country:US
Practice Address - Phone:541-900-4285
Practice Address - Fax:888-810-2993
Is Sole Proprietor?:Yes
Enumeration Date:2015-10-12
Last Update Date:2024-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101Y00000X
ORR4988101YM0800X
ORC6868101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500745772Medicaid