=====================================================
General NPI Number Information
=====================================================
NPI Number | 1316267156
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CHARLOTTE ROSE CARLSON LCPC
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/03/2010
-----------------------------------------------------
Last Update Date | 05/07/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1405 4TH ST SW STE 7
-----------------------------------------------------
City | SIDNEY
-----------------------------------------------------
State | MT
-----------------------------------------------------
Zip | 59270-3515
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 406-643-9045
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 110
-----------------------------------------------------
City | SIDNEY
-----------------------------------------------------
State | MT
-----------------------------------------------------
Zip | 59270-0110
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 406-643-4095
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number | LPC-1825
-----------------------------------------------------
License Number State | WY
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number | 19540
-----------------------------------------------------
License Number State | MT
-----------------------------------------------------