Provider Demographics
NPI:1417394297
Name:PEDERSON, CARLY P (ATC/R)
Entity Type:Individual
Prefix:
First Name:CARLY
Middle Name:P
Last Name:PEDERSON
Suffix:
Gender:F
Credentials:ATC/R
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:516 15TH AVE SE
Mailing Address - Street 2:ROOM 190
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55455-0130
Mailing Address - Country:US
Mailing Address - Phone:612-518-7270
Mailing Address - Fax:
Practice Address - Street 1:18929 149TH ST NW
Practice Address - Street 2:
Practice Address - City:ELK RIVER
Practice Address - State:MN
Practice Address - Zip Code:55330-8362
Practice Address - Country:US
Practice Address - Phone:612-518-7270
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-06-03
Last Update Date:2021-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN24332255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer