Healthcare Provider Details

I. General information

NPI: 1568521235
Provider Name (Legal Business Name): CAROLYN CARLSON M.ED., LADC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/08/2006
Last Update Date: 01/10/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

149 W CORNWALL RD
SHARON CT
06069-2105
US

IV. Provider business mailing address

38 OLD RIDGEBURY RD
DANBURY CT
06810-5128
US

V. Phone/Fax

Practice location:
  • Phone: 860-672-6689
  • Fax: 860-672-3021
Mailing address:
  • Phone: 203-792-4515
  • Fax: 203-748-2604

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number000052
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: