Provider Demographics
NPI:1437637865
Name:CARLSON, MALLORY E (LAC)
Entity Type:Individual
Prefix:
First Name:MALLORY
Middle Name:E
Last Name:CARLSON
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1631 SELBY AVE APT 4
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55104-6273
Mailing Address - Country:US
Mailing Address - Phone:612-800-4297
Mailing Address - Fax:
Practice Address - Street 1:2545 CHICAGO AVE STE G10
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55404-4569
Practice Address - Country:US
Practice Address - Phone:612-353-6318
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-28
Last Update Date:2018-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1722171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist