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NPI Code Detail

MEDICARE: INA S. CARLSON PH.D., HSPP

MEDICARE: INA S. CARLSON PH.D., HSPP
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1103TC0700XClinical Psychologist20090244AIN

General Provider Information

NPI Number : 1265490650
Entity Type Code : Individual
Provider Name (Legal Business Name) : INA S. CARLSON PH.D., HSPP
Provider Business Mailing Address
First Line : 11109 PARKVIEW PLAZA DR # 117
Second Line :
City : FORT WAYNE
State : IN
Zip : 46845-1701
Country : US
Telephone Number :
Fax Number :
Provider Business Practice Location Address
First Line : 1909 CAREW ST
Second Line :
City : FORT WAYNE
State : IN
Zip : 46805-4707
Country : US
Telephone Number : 260-481-2800
Fax Number : 260-969-8442
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 05/03/2006
Last Update Date : 10/17/2022

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