Provider Demographics
NPI:1679021166
Name:CARLSON, MARY L (MS, LPC)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:L
Last Name:CARLSON
Suffix:
Gender:F
Credentials:MS, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:308 S FRIENDSWOOD DR STE 200
Mailing Address - Street 2:
Mailing Address - City:FRIENDSWOOD
Mailing Address - State:TX
Mailing Address - Zip Code:77546-3989
Mailing Address - Country:US
Mailing Address - Phone:844-824-8775
Mailing Address - Fax:
Practice Address - Street 1:1300 S UNIVERSITY DR STE 306
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76107-5746
Practice Address - Country:US
Practice Address - Phone:844-824-8775
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-14
Last Update Date:2024-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2014030086101YP2500X
TX79257101YP2500X, 101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional