Healthcare Provider Details

I. General information

NPI: 1104571520
Provider Name (Legal Business Name): AMY BETH CARLSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/14/2022
Last Update Date: 06/19/2026
Certification Date: 06/19/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2700 E FOOTHILL BLVD
PASADENA CA
91107-7100
US

IV. Provider business mailing address

2335 E COLORADO BLVD STE 115-306
PASADENA CA
91107-6833
US

V. Phone/Fax

Practice location:
  • Phone: 626-887-8592
  • Fax:
Mailing address:
  • Phone: 262-378-0513
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number163439
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: