Healthcare Provider Details

I. General information

NPI: 1427556240
Provider Name (Legal Business Name): NICOLE CARLSON LCSW, PMHNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/26/2018
Last Update Date: 03/14/2026
Certification Date: 03/14/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2600 E SOUTHERN AVE STE C3
TEMPE AZ
85282-7609
US

IV. Provider business mailing address

2600 E SOUTHERN AVE STE C3
TEMPE AZ
85282-7609
US

V. Phone/Fax

Practice location:
  • Phone: 626-515-8875
  • Fax:
Mailing address:
  • Phone: 626-515-8875
  • Fax: 480-879-3048

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number276452
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLCSW-19986
License Number StateAZ
# 3
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number276452
License Number StateAZ
# 4
Primary TaxonomyN
Taxonomy Code163WP0808X
TaxonomyPsychiatric/Mental Health Registered Nurse
License NumberAP70017008
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: