Provider Demographics
NPI:1942510755
Name:CARLSON, ALICIA D (MS, LPC, NCC, CSAC)
Entity type:Individual
Prefix:MS
First Name:ALICIA
Middle Name:D
Last Name:CARLSON
Suffix:
Gender:F
Credentials:MS, LPC, NCC, CSAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10561 N RIVERSIDE RD
Mailing Address - Street 2:
Mailing Address - City:HAYWARD
Mailing Address - State:WI
Mailing Address - Zip Code:54843-4015
Mailing Address - Country:US
Mailing Address - Phone:715-699-0205
Mailing Address - Fax:
Practice Address - Street 1:10610 MAIN ST STE 224
Practice Address - Street 2:
Practice Address - City:HAYWARD
Practice Address - State:WI
Practice Address - Zip Code:54843-6586
Practice Address - Country:US
Practice Address - Phone:715-634-4806
Practice Address - Fax:715-634-5387
Is Sole Proprietor?:No
Enumeration Date:2010-10-14
Last Update Date:2015-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI5275-125101YP2500X, 101YM0800X
WI15916-131101YA0400X
WI15898-132101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI100036439Medicaid