MEDICARE: MS. VIVIAN DALE 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	101Y00000X	Counselor

General Provider Information

NPI Number	:	1437431319
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. VIVIAN DALE CARLSON

Provider Business Mailing Address
First Line	:	1213 FIELDSTONE WAY
Second Line	:
City	:	MUSTANG
State	:	OK
Zip	:	73064-7010
Country	:	US
Telephone Number	:	320-310-6888
Fax Number	:

Provider Business Practice Location Address
First Line	:	4545 N LINCOLN BLVD
Second Line	:	105
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73105-3418
Country	:	US
Telephone Number	:	405-501-8405
Fax Number	:

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

Provider Enumeration Date	:	09/15/2011
Last Update Date	:	06/12/2014

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