Provider Demographics
NPI:1336646819
Name:CARLSON, ELENITA MANDILAG (PT)
Entity Type:Individual
Prefix:
First Name:ELENITA
Middle Name:MANDILAG
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 1:14745 MERCURY DR
Mailing Address - Street 2:
Mailing Address - City:GRAND HAVEN
Mailing Address - State:MI
Mailing Address - Zip Code:49417-9703
Mailing Address - Country:US
Mailing Address - Phone:973-960-1216
Mailing Address - Fax:
Practice Address - Street 1:900 S BEACON BLVD
Practice Address - Street 2:
Practice Address - City:GRAND HAVEN
Practice Address - State:MI
Practice Address - Zip Code:49417-2146
Practice Address - Country:US
Practice Address - Phone:616-846-1850
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-04-10
Last Update Date:2018-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501013549225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist