Provider Demographics
NPI:1467735407
Name:MATTSON, CARLY L (PT)
Entity Type:Individual
Prefix:MS
First Name:CARLY
Middle Name:L
Last Name:MATTSON
Suffix:
Gender:F
Credentials:PT
Other - Prefix:MS
Other - First Name:CARLY
Other - Middle Name:L
Other - Last Name:SCHULTZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:11855 ULYSSES ST NE
Mailing Address - Street 2:STE 20
Mailing Address - City:BLAINE
Mailing Address - State:MN
Mailing Address - Zip Code:55434-3947
Mailing Address - Country:US
Mailing Address - Phone:763-767-3140
Mailing Address - Fax:763-767-3146
Practice Address - Street 1:11855 ULYSSES ST NE
Practice Address - Street 2:STE 20
Practice Address - City:BLAINE
Practice Address - State:MN
Practice Address - Zip Code:55434-3947
Practice Address - Country:US
Practice Address - Phone:763-767-3140
Practice Address - Fax:763-767-3146
Is Sole Proprietor?:No
Enumeration Date:2011-09-26
Last Update Date:2012-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN8825225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist