Provider Demographics
NPI:1518352491
Name:CARLSON, ANGELA (DPT)
Entity Type:Individual
Prefix:
First Name:ANGELA
Middle Name:
Last Name:CARLSON
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:110388 HUNT DAIRY RD
Mailing Address - Street 2:
Mailing Address - City:MITCHELL
Mailing Address - State:NE
Mailing Address - Zip Code:69357-2172
Mailing Address - Country:US
Mailing Address - Phone:308-672-4543
Mailing Address - Fax:
Practice Address - Street 1:1060 D ST W
Practice Address - Street 2:
Practice Address - City:VALE
Practice Address - State:OR
Practice Address - Zip Code:97918-1107
Practice Address - Country:US
Practice Address - Phone:541-473-3131
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-03-30
Last Update Date:2015-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPT-4070225100000X
OR60939225100000X
COPTL.0013163225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist