Provider Demographics
NPI:1396359972
Name:CARSON, MONTREL D (LMT)
Entity Type:Individual
Prefix:
First Name:MONTREL
Middle Name:D
Last Name:CARSON
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12032 BROOKSONG DR
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28278-7053
Mailing Address - Country:US
Mailing Address - Phone:704-224-3887
Mailing Address - Fax:
Practice Address - Street 1:12032 BROOKSONG DR
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28278-7053
Practice Address - Country:US
Practice Address - Phone:704-224-3887
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-01
Last Update Date:2020-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC15873225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist