Provider Demographics
NPI:1023302767
Name:CYNTHIA LEIGH CARLSON LLC
Entity type:Organization
Organization Name:CYNTHIA LEIGH CARLSON LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL SOCIAL WORKER
Authorized Official - Prefix:MS
Authorized Official - First Name:CYNTHIA
Authorized Official - Middle Name:LEIGH
Authorized Official - Last Name:CARLSON
Authorized Official - Suffix:
Authorized Official - Credentials:MSW
Authorized Official - Phone:414-963-9187
Mailing Address - Street 1:3970 N OAKLAND AVE STE 704
Mailing Address - Street 2:
Mailing Address - City:SHOREWOOD
Mailing Address - State:WI
Mailing Address - Zip Code:53211-2265
Mailing Address - Country:US
Mailing Address - Phone:414-963-9187
Mailing Address - Fax:
Practice Address - Street 1:3970 N OAKLAND AVE STE 704
Practice Address - Street 2:
Practice Address - City:SHOREWOOD
Practice Address - State:WI
Practice Address - Zip Code:53211-2265
Practice Address - Country:US
Practice Address - Phone:414-963-9187
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-05-28
Last Update Date:2011-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI27061041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty