Provider Demographics
NPI:1154662757
Name:CARLSON, CONNIE KAY (PTA)
Entity Type:Individual
Prefix:MS
First Name:CONNIE
Middle Name:KAY
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 1:4868 W 84TH CT
Mailing Address - Street 2:
Mailing Address - City:CROWN POINT
Mailing Address - State:IN
Mailing Address - Zip Code:46307-1410
Mailing Address - Country:US
Mailing Address - Phone:219-808-3448
Mailing Address - Fax:
Practice Address - Street 1:4868 W 84TH CT
Practice Address - Street 2:
Practice Address - City:CROWN POINT
Practice Address - State:IN
Practice Address - Zip Code:46307-1410
Practice Address - Country:US
Practice Address - Phone:219-808-3448
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-03-06
Last Update Date:2013-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN06002768A225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant