Healthcare Provider Details

I. General information

NPI: 1396005989
Provider Name (Legal Business Name): JOHN V. CARLSON PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/17/2012
Last Update Date: 05/17/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 SUMMIT ST
HARTFORD CT
06106-3100
US

IV. Provider business mailing address

10 AVONDALE RD
MANCHESTER CT
06042-3258
US

V. Phone/Fax

Practice location:
  • Phone: 860-305-3024
  • Fax:
Mailing address:
  • Phone: 860-305-3024
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number003138
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: