MEDICARE: DR. LEANNE CARLSON PHD HSPP

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	103TC0700X	Clinical Psychologist	20040653A	IN

General Provider Information

NPI Number	:	1295735744
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. LEANNE CARLSON PHD HSPP

Provider Business Mailing Address
First Line	:	50 E 91ST ST
Second Line	:	STE 208
City	:	INDIANAPOLIS
State	:	IN
Zip	:	46240
Country	:	US
Telephone Number	:	317-431-0897
Fax Number	:	317-598-0355

Provider Business Practice Location Address
First Line	:	50 E 91ST ST
Second Line	:	STE 208
City	:	INDIANAPOLIS
State	:	IN
Zip	:	46240
Country	:	US
Telephone Number	:	317-431-0897
Fax Number	:	317-598-0355

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

Provider Enumeration Date	:	07/27/2005
Last Update Date	:	07/08/2007

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