Provider Demographics
NPI:1861938862
Name:CARLSON, KAYLA (LCSW)
Entity type:Individual
Prefix:
First Name:KAYLA
Middle Name:
Last Name:CARLSON
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3511 S 9TH ST
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:IN
Mailing Address - Zip Code:47909-3545
Mailing Address - Country:US
Mailing Address - Phone:765-423-5361
Mailing Address - Fax:765-742-8272
Practice Address - Street 1:615 N 18TH ST STE 101
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:IN
Practice Address - Zip Code:47904-3413
Practice Address - Country:US
Practice Address - Phone:765-423-5361
Practice Address - Fax:765-742-8272
Is Sole Proprietor?:No
Enumeration Date:2017-01-13
Last Update Date:2019-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN99077229A104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN99077229AOtherLSW
IN13938925OtherCAQH
IN34008518AOtherLCSW