Provider Demographics
NPI:1366511354
Name:CARLSON, SHERIE LYNN (PHD, LP)
Entity type:Individual
Prefix:MRS
First Name:SHERIE
Middle Name:LYNN
Last Name:CARLSON
Suffix:
Gender:F
Credentials:PHD, LP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24599 165TH ST
Mailing Address - Street 2:
Mailing Address - City:GLENWOOD
Mailing Address - State:MN
Mailing Address - Zip Code:56334
Mailing Address - Country:US
Mailing Address - Phone:320-491-7783
Mailing Address - Fax:320-762-0796
Practice Address - Street 1:324 BROADWAY ST
Practice Address - Street 2:STE 206
Practice Address - City:ALEXANDRIA
Practice Address - State:MN
Practice Address - Zip Code:56308-1482
Practice Address - Country:US
Practice Address - Phone:320-762-1762
Practice Address - Fax:320-762-0796
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-06
Last Update Date:2016-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP3982103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN936488900Medicaid
136937OtherBHP
MN218G2MAOtherBLUE CROSS BLUE SHIELD
MN936488900OtherPRIMEWEST HEALTH SYSTEMS
6267225OtherUBH