Provider Demographics
NPI:1710102595
Name:CARLSON, CAROL VICTOR (DOCTORATE - PHD)
Entity type:Individual
Prefix:DR
First Name:CAROL
Middle Name:VICTOR
Last Name:CARLSON
Suffix:
Gender:F
Credentials:DOCTORATE - PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:405 ROCKEFELLER UNIT 906
Mailing Address - Street 2:
Mailing Address - City:IRVINE
Mailing Address - State:CA
Mailing Address - Zip Code:92612-7192
Mailing Address - Country:US
Mailing Address - Phone:510-444-1110
Mailing Address - Fax:949-885-8885
Practice Address - Street 1:4199 CAMPUS DR STE 550
Practice Address - Street 2:
Practice Address - City:IRVINE
Practice Address - State:CA
Practice Address - Zip Code:92612-4694
Practice Address - Country:US
Practice Address - Phone:510-444-1110
Practice Address - Fax:949-885-8885
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-16
Last Update Date:2024-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY14518103TC0700X, 103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA0PL145180OtherBLUE SHIELD PROVIDER #