MEDICARE: DR. TRACY NICOLE CARLSON PH.D.

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	103TC1900X	Counseling Psychologist	1405	LA
2	103TC1900X	Counseling Psychologist

General Provider Information

NPI Number	:	1356657340
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. TRACY NICOLE CARLSON PH.D.

Provider Business Mailing Address
First Line	:	1300 SOUTH 2ND STREET, SUITE 180
Second Line	:	CENTER FOR SEXUAL HEALTH
City	:	MINNEAPOLIS
State	:	MN
Zip	:	55454
Country	:	US
Telephone Number	:	612-625-1500
Fax Number	:

Provider Business Practice Location Address
First Line	:	200 W ESPLANADE AVE STE 412
Second Line	:
City	:	KENNER
State	:	LA
Zip	:	70065-2475
Country	:	US
Telephone Number	:	504-464-2940
Fax Number	:	504-464-2941

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

Provider Enumeration Date	:	08/27/2010
Last Update Date	:	09/17/2018

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