Healthcare Provider Details

I. General information

NPI: 1639388747
Provider Name (Legal Business Name): ELIZABETH CARLSON PH.D., L.P.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/22/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

570 ASBURY ST
SAINT PAUL MN
55104-1849
US

IV. Provider business mailing address

51 E RIVER RD
MINNEAPOLIS MN
55455-0365
US

V. Phone/Fax

Practice location:
  • Phone: 651-646-7010
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC2200X
TaxonomyClinical Child & Adolescent Psychologist
License NumberLP3119
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: