Provider Demographics
NPI:1174758569
Name:CARLSON, STEPHEN HAYNES (PSYD)
Entity type:Individual
Prefix:MR
First Name:STEPHEN
Middle Name:HAYNES
Last Name:CARLSON
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2446 24TH AVE
Mailing Address - Street 2:
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94601-1267
Mailing Address - Country:US
Mailing Address - Phone:510-566-1076
Mailing Address - Fax:
Practice Address - Street 1:298 GRAND AVE
Practice Address - Street 2:#100
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94610-4724
Practice Address - Country:US
Practice Address - Phone:510-566-1076
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-05-28
Last Update Date:2016-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY 27819103TC0700X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical