Provider Demographics
NPI:1003163569
Name:CARLSON, ELISABETH LEE (L AC MSTOM)
Entity Type:Individual
Prefix:
First Name:ELISABETH
Middle Name:LEE
Last Name:CARLSON
Suffix:
Gender:F
Credentials:L AC MSTOM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:850 S GREENVILLE AVE
Mailing Address - Street 2:SUITE 103
Mailing Address - City:RICHARDSON
Mailing Address - State:TX
Mailing Address - Zip Code:75081-5090
Mailing Address - Country:US
Mailing Address - Phone:773-386-5843
Mailing Address - Fax:
Practice Address - Street 1:850 S GREENVILLE AVE
Practice Address - Street 2:SUITE 103
Practice Address - City:RICHARDSON
Practice Address - State:TX
Practice Address - Zip Code:75081-5090
Practice Address - Country:US
Practice Address - Phone:972-669-1346
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-08-14
Last Update Date:2013-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAC01415171100000X
IL198000965171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist