Provider Demographics
NPI:1164515177
Name:CARLSON, RENEE (PT)
Entity Type:Individual
Prefix:
First Name:RENEE
Middle Name:
Last Name:CARLSON
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9404 GENESEE AVE
Mailing Address - Street 2:SUITE 310
Mailing Address - City:LA JOLLA
Mailing Address - State:CA
Mailing Address - Zip Code:92037-1339
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:9404 GENESEE AVE
Practice Address - Street 2:SUITE 310
Practice Address - City:LA JOLLA
Practice Address - State:CA
Practice Address - Zip Code:92037-1339
Practice Address - Country:US
Practice Address - Phone:858-455-1195
Practice Address - Fax:858-455-7101
Is Sole Proprietor?:No
Enumeration Date:2006-10-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT16834225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist