MEDICARE: DAVID K. CARLSON PSY.D.

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
1	103TC0700X	Clinical Psychologist	37506	TX

General Provider Information

NPI Number	:	1326582941
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DAVID K. CARLSON PSY.D.

Provider Business Mailing Address
First Line	:	5112 LEERAY RD
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76244-9233
Country	:	US
Telephone Number	:	405-819-9655
Fax Number	:

Provider Business Practice Location Address
First Line	:	5112 LEERAY RD
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76244-9233
Country	:	US
Telephone Number	:	405-819-9655
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/16/2016
Last Update Date	:	12/16/2016

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