Provider Demographics
NPI:1598235863
Name:CARLSON, CARMEN DANIELLE (LPTA/DOR)
Entity Type:Individual
Prefix:
First Name:CARMEN
Middle Name:DANIELLE
Last Name:CARLSON
Suffix:
Gender:F
Credentials:LPTA/DOR
Other - Prefix:
Other - First Name:CARMEN
Other - Middle Name:DANIELLE
Other - Last Name:FILLION
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LPTA
Mailing Address - Street 1:916 E LEWIS ST
Mailing Address - Street 2:
Mailing Address - City:WHITEHALL
Mailing Address - State:MI
Mailing Address - Zip Code:49461-1699
Mailing Address - Country:US
Mailing Address - Phone:231-894-4056
Mailing Address - Fax:231-893-1963
Practice Address - Street 1:916 E LEWIS ST
Practice Address - Street 2:
Practice Address - City:WHITEHALL
Practice Address - State:MI
Practice Address - Zip Code:49461-1699
Practice Address - Country:US
Practice Address - Phone:231-894-4056
Practice Address - Fax:231-893-1963
Is Sole Proprietor?:No
Enumeration Date:2018-11-29
Last Update Date:2018-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5502000476225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant