Provider Demographics
NPI:1477719151
Name:CARLSON, KENT (PT, MPT)
Entity Type:Individual
Prefix:
First Name:KENT
Middle Name:
Last Name:CARLSON
Suffix:
Gender:M
Credentials:PT, MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4240 S COVENTRY RD
Mailing Address - Street 2:
Mailing Address - City:NEW BERLIN
Mailing Address - State:WI
Mailing Address - Zip Code:53151-6145
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2835 N GRANDVIEW BLVD
Practice Address - Street 2:SUITE 100
Practice Address - City:PEWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53072-5546
Practice Address - Country:US
Practice Address - Phone:262-574-5185
Practice Address - Fax:262-574-5193
Is Sole Proprietor?:No
Enumeration Date:2008-08-01
Last Update Date:2011-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI10398-024225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1477719151Medicaid
WI001683042Medicare PIN
WI832070036Medicare PIN