Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 101YP2500X | Professional Counselor | 2015040235 | MO |
NPI | 1003455478 |
---|---|
Provider Name | Amy Lou Carlson |
First Address | Parkville, MO 64152-2460 |
Second Address | Parkville, MO 64152-2460 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 02/01/2020 |
Last Update Date | 02/01/2020 |