Provider Demographics
NPI:1538635396
Name:CARLSON, AMELIA ALEXANDRA
Entity Type:Individual
Prefix:MRS
First Name:AMELIA
Middle Name:ALEXANDRA
Last Name:CARLSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:AMELIA
Other - Middle Name:ALEXANDRA
Other - Last Name:REEK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1108 16TH ST N
Mailing Address - Street 2:
Mailing Address - City:PRINCETON
Mailing Address - State:MN
Mailing Address - Zip Code:55371-6163
Mailing Address - Country:US
Mailing Address - Phone:763-843-7094
Mailing Address - Fax:
Practice Address - Street 1:1108 16TH ST N
Practice Address - Street 2:
Practice Address - City:PRINCETON
Practice Address - State:MN
Practice Address - Zip Code:55371-6163
Practice Address - Country:US
Practice Address - Phone:763-843-7094
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-19
Last Update Date:2019-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN32462255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer