Provider Demographics
NPI:1205212511
Name:CARLSON, REBECCA MERRELL (LM, CPM)
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:MERRELL
Last Name:CARLSON
Suffix:
Gender:F
Credentials:LM, CPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12285 SE 70TH AVENUE RD
Mailing Address - Street 2:
Mailing Address - City:BELLEVIEW
Mailing Address - State:FL
Mailing Address - Zip Code:34420-4673
Mailing Address - Country:US
Mailing Address - Phone:352-470-7565
Mailing Address - Fax:
Practice Address - Street 1:12285 SE 70TH AVENUE RD
Practice Address - Street 2:
Practice Address - City:BELLEVIEW
Practice Address - State:FL
Practice Address - Zip Code:34420-4673
Practice Address - Country:US
Practice Address - Phone:352-470-7565
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-08-10
Last Update Date:2021-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
374J00000X
FLMW408176B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes176B00000XOther Service ProvidersMidwife
No374J00000XNursing Service Related ProvidersDoula