Provider Demographics
NPI:1295850378
Name:CARLSON, LYNN M (PT)
Entity Type:Individual
Prefix:MR
First Name:LYNN
Middle Name:M
Last Name:CARLSON
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:408 HIGUERA ST STE 200
Mailing Address - Street 2:
Mailing Address - City:SAN LUIS OBISPO
Mailing Address - State:CA
Mailing Address - Zip Code:93401-6135
Mailing Address - Country:US
Mailing Address - Phone:805-788-0805
Mailing Address - Fax:805-788-0845
Practice Address - Street 1:7483 E TANQUE VERDE RD
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85715-3477
Practice Address - Country:US
Practice Address - Phone:520-207-7220
Practice Address - Fax:520-207-7109
Is Sole Proprietor?:No
Enumeration Date:2007-03-20
Last Update Date:2023-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1772225100000X
WI11003225100000X, 225100000X
AZLPT000704225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1295850378Medicaid
AZ1295850378Medicaid