Provider Demographics
NPI:1871967331
Name:CARLSON, AMBER DAWN (LICSW)
Entity type:Individual
Prefix:MRS
First Name:AMBER
Middle Name:DAWN
Last Name:CARLSON
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:939 MOUNTAIN VIEW DR
Mailing Address - Street 2:
Mailing Address - City:SHELTON
Mailing Address - State:WA
Mailing Address - Zip Code:98584-4410
Mailing Address - Country:US
Mailing Address - Phone:360-432-7782
Mailing Address - Fax:
Practice Address - Street 1:939 MOUNTAIN VIEW DR
Practice Address - Street 2:
Practice Address - City:SHELTON
Practice Address - State:WA
Practice Address - Zip Code:98584-4410
Practice Address - Country:US
Practice Address - Phone:360-432-7782
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-11-20
Last Update Date:2016-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALW60294111101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor