Provider Demographics
NPI:1437904042
Name:CARLSON, MINDY
Entity Type:Individual
Prefix:
First Name:MINDY
Middle Name:
Last Name:CARLSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:927 W 770 S
Mailing Address - Street 2:
Mailing Address - City:TOOELE
Mailing Address - State:UT
Mailing Address - Zip Code:84074-3088
Mailing Address - Country:US
Mailing Address - Phone:435-840-8310
Mailing Address - Fax:
Practice Address - Street 1:85 E 2000 N
Practice Address - Street 2:
Practice Address - City:TOOELE
Practice Address - State:UT
Practice Address - Zip Code:84074-9280
Practice Address - Country:US
Practice Address - Phone:435-840-8310
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-04-18
Last Update Date:2024-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT8034667-4003225800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225800000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRecreation Therapist