Provider Demographics
NPI:1083072359
Name:CARLSON, AMY GRACE (PTA)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:GRACE
Last Name:CARLSON
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1207 JENKS BLVD
Mailing Address - Street 2:
Mailing Address - City:KALAMAZOO
Mailing Address - State:MI
Mailing Address - Zip Code:49006-2105
Mailing Address - Country:US
Mailing Address - Phone:269-823-3707
Mailing Address - Fax:
Practice Address - Street 1:1701 S 11TH ST
Practice Address - Street 2:
Practice Address - City:KALAMAZOO
Practice Address - State:MI
Practice Address - Zip Code:49009-1775
Practice Address - Country:US
Practice Address - Phone:269-375-2020
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-02-02
Last Update Date:2016-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5502002404225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant