Provider Demographics
NPI:1568786739
Name:CARLSON, KELLEY RENEA (MPT, OMPT)
Entity Type:Individual
Prefix:MS
First Name:KELLEY
Middle Name:RENEA
Last Name:CARLSON
Suffix:
Gender:F
Credentials:MPT, OMPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:101 W END AVE
Mailing Address - Street 2:APT 23D
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10023-6349
Mailing Address - Country:US
Mailing Address - Phone:248-709-5490
Mailing Address - Fax:
Practice Address - Street 1:101 W END AVE
Practice Address - Street 2:APT 23D
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10023-6349
Practice Address - Country:US
Practice Address - Phone:248-709-5490
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-03-17
Last Update Date:2010-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY62030102225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist