MEDICARE: AMY BETH CARLSON

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	390200000X	Student in an Organized Health Care Education/Training Program
2	106H00000X	Marriage & Family Therapist	163439	CA

General Provider Information

NPI Number	:	1104571520
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	AMY BETH CARLSON

Provider Business Mailing Address
First Line	:	2335 E COLORADO BLVD STE 115-306
Second Line	:
City	:	PASADENA
State	:	CA
Zip	:	91107-6833
Country	:	US
Telephone Number	:	262-378-0513
Fax Number	:

Provider Business Practice Location Address
First Line	:	2700 E FOOTHILL BLVD
Second Line	:
City	:	PASADENA
State	:	CA
Zip	:	91107-7100
Country	:	US
Telephone Number	:	626-887-8592
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/14/2022
Last Update Date	:	06/19/2026

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