Healthcare Provider Details

I. General information

NPI: 1841882594
Provider Name (Legal Business Name): JULIE ANN CARLSON LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/04/2021
Last Update Date: 02/12/2025
Certification Date: 02/12/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2275 W BROADWAY ST STE G
IDAHO FALLS ID
83402-2902
US

IV. Provider business mailing address

560 W SUNNYSIDE RD STE D
IDAHO FALLS ID
83402-4641
US

V. Phone/Fax

Practice location:
  • Phone: 208-524-7400
  • Fax:
Mailing address:
  • Phone: 208-274-4720
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: