Provider Demographics
NPI:1700365517
Name:CARLSON, JOHN E
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:E
Last Name:CARLSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15 NIMS ST
Mailing Address - Street 2:
Mailing Address - City:CROSWELL
Mailing Address - State:MI
Mailing Address - Zip Code:48422-1233
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:227 E SANILAC RD
Practice Address - Street 2:
Practice Address - City:SANDUSKY
Practice Address - State:MI
Practice Address - Zip Code:48471-1160
Practice Address - Country:US
Practice Address - Phone:810-648-0330
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-13
Last Update Date:2024-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010893581041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical