Provider Demographics
NPI:1225713589
Name:CARLSON, MCKENZE (DPT)
Entity Type:Individual
Prefix:
First Name:MCKENZE
Middle Name:
Last Name:CARLSON
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4114 N 28TH ST APT 3017
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85016-5779
Mailing Address - Country:US
Mailing Address - Phone:712-577-3347
Mailing Address - Fax:
Practice Address - Street 1:211 N ESTRELLA PKWY STE 103-104
Practice Address - Street 2:
Practice Address - City:GOODYEAR
Practice Address - State:AZ
Practice Address - Zip Code:85338-9339
Practice Address - Country:US
Practice Address - Phone:623-323-1010
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-06-15
Last Update Date:2023-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZCP021778T225100000X
SD2581225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist