Provider Demographics
NPI:1265758890
Name:CARLSON, KRISTINE MARIE (LLMSW AND LLCSW)
Entity type:Individual
Prefix:MS
First Name:KRISTINE
Middle Name:MARIE
Last Name:CARLSON
Suffix:
Gender:F
Credentials:LLMSW AND LLCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2269 OVERRIDGE AVE
Mailing Address - Street 2:
Mailing Address - City:WATERFORD
Mailing Address - State:MI
Mailing Address - Zip Code:48327-1149
Mailing Address - Country:US
Mailing Address - Phone:734-624-2361
Mailing Address - Fax:
Practice Address - Street 1:2269 OVERRIDGE AVE
Practice Address - Street 2:
Practice Address - City:WATERFORD
Practice Address - State:MI
Practice Address - Zip Code:48327-1149
Practice Address - Country:US
Practice Address - Phone:734-624-2361
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-04-07
Last Update Date:2010-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLISW59251041C0700X
MI6801091979104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical