Provider Demographics
NPI:1255670568
Name:CARLSON, RICHARD MERLE (OTR/L)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:MERLE
Last Name:CARLSON
Suffix:
Gender:M
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5245 NORTH SOCRUM LOOP ROAD
Mailing Address - Street 2:
Mailing Address - City:LAKELAND
Mailing Address - State:FL
Mailing Address - Zip Code:33823
Mailing Address - Country:US
Mailing Address - Phone:863-859-1446
Mailing Address - Fax:863-859-4307
Practice Address - Street 1:5245 NORTH SOCRUM LOOP ROAD
Practice Address - Street 2:
Practice Address - City:LAKELAND
Practice Address - State:FL
Practice Address - Zip Code:33823
Practice Address - Country:US
Practice Address - Phone:863-859-1446
Practice Address - Fax:863-859-4307
Is Sole Proprietor?:Yes
Enumeration Date:2013-02-06
Last Update Date:2013-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOT6217225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist