MEDICARE: DR. LARRY JAMES 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	103TB0200X	Cognitive & Behavioral Psychologist	152	WY
2	103TC0700X	Clinical Psychologist	152	WY

General Provider Information

NPI Number	:	1609043223
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. LARRY JAMES CARLSON PH.D

Provider Business Mailing Address
First Line	:	2632 FOOTHILL BLVD
Second Line	:	SUITE 106
City	:	ROCK SPRINGS
State	:	WY
Zip	:	82901-4756
Country	:	US
Telephone Number	:	307-362-8840
Fax Number	:	307-362-8840

Provider Business Practice Location Address
First Line	:	2632 FOOTHILL BLVD
Second Line	:	SUITE 106
City	:	ROCK SPRINGS
State	:	WY
Zip	:	82901-4756
Country	:	US
Telephone Number	:	307-362-8840
Fax Number	:	307-362-8840

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

Provider Enumeration Date	:	05/13/2008
Last Update Date	:	05/13/2008

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