Healthcare Provider Details

I. General information

NPI: 1356657340
Provider Name (Legal Business Name): TRACY NICOLE CARLSON PH.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: TRACY N CARLSON PHD

II. Dates (important events)

Enumeration Date: 08/27/2010
Last Update Date: 09/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 W ESPLANADE AVE STE 412
KENNER LA
70065-2475
US

IV. Provider business mailing address

1300 SOUTH 2ND STREET, SUITE 180 CENTER FOR SEXUAL HEALTH
MINNEAPOLIS MN
55454
US

V. Phone/Fax

Practice location:
  • Phone: 504-464-2940
  • Fax: 504-464-2941
Mailing address:
  • Phone: 612-625-1500
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License Number1405
License Number StateLA
# 2
Primary TaxonomyY
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: