Provider Demographics
NPI:1467980821
Name:FOSTER CARLSON, TISHA MARIE (DPT)
Entity Type:Individual
Prefix:
First Name:TISHA
Middle Name:MARIE
Last Name:FOSTER CARLSON
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:TISHA
Other - Middle Name:MARIE
Other - Last Name:CARLSON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DPT
Mailing Address - Street 1:202 E TAPADERA ST
Mailing Address - Street 2:
Mailing Address - City:GILLETTE
Mailing Address - State:WY
Mailing Address - Zip Code:82718-7848
Mailing Address - Country:US
Mailing Address - Phone:307-688-8000
Mailing Address - Fax:
Practice Address - Street 1:508 STOCKTRAIL AVE STE D
Practice Address - Street 2:
Practice Address - City:GILLETTE
Practice Address - State:WY
Practice Address - Zip Code:82716-3582
Practice Address - Country:US
Practice Address - Phone:307-688-8000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-05-30
Last Update Date:2017-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY1184225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist